Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (93228) and 
myocardial perfusion imaging, tomographic (SPECT) (78452). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry (93228) and myocardial perfusion 
imaging, tomographic (SPECT) (78452). You say that the requested external mobile cardiovascular telemetry 
(93228) and myocardial perfusion imaging, tomographic (SPECT) (78452) are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested external mobile 
cardiovascular telemetry (93228) and myocardial perfusion imaging, tomographic (SPECT) (78452). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve external mobile cardiovascular 
telemetry (93228) and myocardial perfusion imaging, tomographic (SPECT) (78452). Our reviewer says that 
the enrollee does not meet criteria for the requested external mobile cardiovascular telemetry (93228) and 
myocardial perfusion imaging, tomographic (SPECT) (78452). Our physician reviewer found the enrollee is to 
undergo rotator cuff surgery, whose physician has requested authorization for myocardial perfusion imaging, 
tomographic (SPECT) imaging and mobile cardiovascular outpatient ECG telemetry (MCOT). There is no 
evidence provided that would support the need for either study at this time. In summary, there is insufficient 
documentation to support the medical necessity for the requested SPECT or MCOT testing in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry (93228) and myocardial perfusion 
imaging, tomographic (SPECT) (78452) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve external mobile cardiovascular telemetry (93228) and myocardial perfusion imaging, 
tomographic (SPECT) (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion (27279, 22514). 
 
You asked the Plan to pre-approve the sacroiliac joint fusion. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sacroiliac joint fusion. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear history of sacroiliac joint pain onset or failure of conservative 
treatment directed to the sacroiliac joint. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sacroiliac joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint fusion (27279, 22514).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (80053, 80306, 81001, 82948, 84703, 85027, 
87631, A9270 and G0480) provided from May 9, 2022, to May 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this is not a duplicate claim. The Plan denied 
your request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has provided no evidence to 
show that these services have previously been paid under a duplicate claim. In addition, codes billed with the 
GY modifier are still subject to review to verify that the modifier was used properly; however, it does not 
appear that this review occurred at the Plan level. Based on this information, we decided that Medicare rules 
for coverage of laboratory services have been met. Therefore, we decided that the Plan has to pay for laboratory 
services (80053, 80306, 81001, 82948, 84703, 85027, 87631, A9270 and G0480) provided from May 9, 2022, 
to May 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod Dash pods. 
 
You asked the Plan to pre-approve Omnipod Dash pods. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Omnipod Dash pods are not covered under the 
enrollee's Medicare Part B benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omnipod Dash pods.  
 
Benefits for Omnipod Dash pods may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from March 25, 2019, to April 6, 
2019. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the review changed the DRG from 374 to 
375. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRg 374. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the secondary diagnosis in question is D61.810- other pancytopenia. The enrollee had small bowel obstruction, 
developed refeeding syndrome with electrolyte changes and had pancytopenia, chemotherapy induced. The 
diagnosis code D61.810 was present - hG was less than 10, and the absolute neutrophil count of .8 and 
treatment was provided with a transfusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from March 25, 2019, to April 6, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complex cataract surgery. 
 
You asked the Plan to pre-approve complex cataract surgery. You say that the requested complex cataract 
surgery is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for coverage of complex cataract surgery. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve complex cataract surgery. Our reviewer 
says that the enrollee does not meet criteria for coverage of complex cataract surgery. Our physician reviewer 
found the enrollee is noted to have a history of trauma, but there are no exam findings to support the requested 
complex cataract surgery. There is normal pupil dilation, 2+ nuclear cataract (not mature), and no 
phacodenesis/zonule weakness noted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of complex cataract surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve complex cataract surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say the member lives alone and requires SNF care to regain 
strength. The Plan denied your request. The Plan says the SNF services requested do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that the enrollee has had acute clinical or functional 
status change and would require assessment by skilled therapy/nursing. All inpatient therapy goals were met 
and there is no specific recommendation given for need of ongoing skilled nursing assessment; Therefore, 
documentation does not show the enrollee requires daily skilled services on an inpatient basis in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure codes 99223 and 99233) rendered 
from June 9, 2022, to June 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code and 99233 and 99233 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is a more appropriate code 
to report for these services provided. In terms of CPT 99223 on June 9, 2022, the medical decision making was 
only of moderate complexity and the history was only problem-focused. Therefore, the code is not supported. 
In terms of CPT 99233 for the other dates of service, the medical decision making was only of moderate 
complexity, and the history and examination was expanded problem focused. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (procedure codes 99223 and 99233) rendered from June 9, 2022, to June 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator and supplies provided on August 26, 2022. 
 
You asked the Plan to pay for the electrical stimulator and supplies. The Plan denied your request. The Plan 
says that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted, and the proof of delivery is not itemized to indicate the specific supplies. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated August 26, 2022, with the same 
tracking number as the delivery ticket dated August 30, 2022. As such, the records support that the items at 
issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical stimulator and 
supplies provided on August 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a trigger point injection rendered on October 17, 2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records did not contain the necessary documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there was no documentation in the medical records of a detailed history and thorough 
physical examination, distribution pattern of pain consistent with the referral pattern of trigger points, 
restriction of range of motion with increased sensitivity to stretch, reproduction of referred pain pattern upon 
stimulation of the trigger point, and reason for selecting the trigger point injection as a therapeutic option. The 
review has determined that the enrollee did not have a reasonable covered indication for trigger point 
injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a trigger point injection rendered on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member's provider believes additional care is 
required. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no face-to-face evaluation with the physician, a standard written order for the 
device, or a home evaluation. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the vehicle. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that the patient has a personal mobility deficit that impairs participation in 
MRADLs. The documentation does not reveal that the patient is unable to use a walker, cane or manual 
wheelchair. The documentation does not reveal that the patient can safely operate this device with adequate 
maneuvering space in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.