Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 11, 2021, to July 
14, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 diagnosis code N17.9. 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 use of diagnosis code N17.9 is not supported by the records provided. Our physician 
reviewer found that the enrollee is an 83-year-old female with a past medical history including chronic kidney 
disease, osteoarthritis, hypertension and urinary incontinence who was admitted to the hospital with lower 
extremity pain after a mechanical fall. She was diagnosed and treated for a deep vein thrombosis. The enrollee 
was treated with IV hydration in the emergency department. Her creatinine was at or near her baseline function. 
There was no indication she had decreased urinary output. The documentation does not indicate that the 
diagnostic work-up and treatment ordered by the treating medical providers supported diagnosis code N17.9 
(Acute kidney failure, unspecified).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 11, 2021, to July 14, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an unattended sleep study (95806). 
 
You asked the Plan to pre-approve an unattended sleep study. The Plan denied your request. The Plan says that 
results of a detailed clinical evaluation, either by face to face or telehealth, was not received to show this study 
is needed. 
 
The Plan follows Medicare rules. Medicare rules say that the evidence is sufficient to determine that the results 
of the sleep tests identified in the Medicare rules section of this letter can be used by a beneficiarys treating 
physician to diagnose obstructive sleep apnea (OSA). 
 
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 an unattended sleep study. Our 
reviewer says that a home sleep study is reasonable and necessary. Our physician reviewer found this enrollee 
has frequent awakening for nocturia, which can be related to unrecognized obstructive sleep apnea (OSA). The 
enrollee is obese, and has occasional high blood pressure readings. Our reviewer found that the Snoring history, 
Tired during the day, Observed stop breathing while sleep, High blood pressure, BMI more than 35 kg/m2, Age 
more than 50 years, Neck circumference more than 40 centimeters, and male Gender (STOP-BANG) shows 
intermediate risk for OSA. Our physician reviewer also found that the enrollee has had a detailed clinical 
evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unattended sleep study have been met. Therefore, we decided that the Plan 
has to pre-approve an unattended sleep study (95806).   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 6, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Medicare 
does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on June 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management. You say that it is the responsibility of the facility to 
obtain an authorization. The Plan denied your request. The Plan says there is no authorization on file for the 
services provided. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chronic care management provided on June 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve injections. You say that this procedure will address the enrollee's symptoms 
of pain. The Plan denied your request. The Plan says the LCD states radiofrequency ablation used for sacroiliac 
joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or 
treatment of sacroiliac joint mediated pain is considered experimental and investigational. Per CMS NCD, 
surgically induced lesions of nerve tracts which involve destruction of nerve tissue are primarily indicated for 
controlling the chronic or acute pain arising from conditions such as terminal cancer or lumbar degenerative 
arthritis. Per the coverage criteria, radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary. The review has determined that the enrollee does not meet the LCD criteria for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 27, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the clinical 
capabilities of all lower levels of care in this geographic region. The Plan denied your request. The Plan says it 
is not safe to leave the hospital at this time, the enrollee is receiving the care needed in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that your rehabilitation is not yet complete and has been 
hindered by a positive COVID-19 test which isolated you and your access to physical and occupational 
therapy. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval 
of continued admission in a SNF does 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist however, based on the medical 
records provided there is no documentation that further daily skilled services are required. Provided records do 
not document a significant decline in your functional status to necessitate further daily inpatient skilled therapy 
services. You do not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Further services in the home with home health care or in a long-term care facility on a 
part time basis are appropriate in this case. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be currently unstable and requires short-term additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate 
for transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous and as 
the patient is not yet stable for transfer. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Alimta (J9305) and chemotherapy administration (96409) provided 
on June 13, 2022. 
 
You asked the Plan to pay for the Alimta and chemotherapy administration. The Plan denied your request. The 
Plan says that the clinical value and effectiveness of Alimta (Pemetrexed) in the setting of neuroendocrine 
tumors have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Alimta and chemotherapy 
administration. Our physician reviewer found the requested use of Alimta is FDA-approved for the enrollees 
diagnosis. This is single-agent treatment (after prior chemotherapy) of recurrent/metastatic non-squamous non-
small cell lung cancer. Our reviewer found the enrollee's large cell neuroendocrine tumor has features of both 
small cell and non-small cell lung cancer. The use is not listed as not indicated, not supported or not 
recommended in any of the compendia. Our physician reviewer also found that the documentation supports that 
the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 Alimta and chemotherapy administration have been met. Therefore, we 
decided that the Plan has to pay for the Alimta (J9305) and chemotherapy administration (96409) provided on 
June 13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need more advanced care than a 
nursing home can provide. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous as you are not yet stable for transfer. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation-problem focused 
(D0140) provided on February 10, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the limited oral evaluation-problem focused (D0140) provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic tire (E2211) and tire-insert (E2213), tray 
(E0950) and stroller handles (K0108) for a wheelchair. 
 
You asked the Plan to pre-approve a pneumatic tire and tire-insert, tray and stroller handles. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items do not serve a primarily medical purpose. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic tire (E2211, E2214) is a rubber tire 
which is used in conjunction with a separate tube (E2212, E2215) which is filled with air. The rules also say 
that for equipment to be covered, it must primarily serve a medical purpose.  
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 pneumatic tire and tire-insert. Our 
reviewer says that a pneumatic tire and insert are not medically reasonable and necessary in this case. Our 
physician reviewer found that pneumatic tires offer an advantage over solid tires when used outdoors. These 
items are not part of standard wheelchair equipment and are not required when a foot box is added to the 
wheelchair. The enrollee is expected to require the wheelchair for limited use due to very limited function. 
 
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 pneumatic tire and tire-insert have not been met. The tray and stroller handles 
at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the 
Plan does not have to pre-approve a pneumatic tire (E2211) and tire-insert (E2213), tray (E0950) and stroller 
handles (K0108) for a wheelchair.
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 enrollee's clinical condition meets the full criteria 
for an inpatient rehabilitation stay. The Plan denied your request. The Plan says the records do not show the 
need for an intensive team or can participate in at least 3 hours of therapy 5 days a week. Medically necessary 
care may be provided safely in a different level of care. 
 
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 clinical documentation does not specify any complex functional impairments or 
active medical issues thus the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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.