Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital-based physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have good functional mobility with right hip pain. There is no documentation of a recent injury or decline in function. The requested hospital-based physical therapy is not at 
an appropriate intensity for treatment of your medical condition and therefore, are not medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the hospital-based physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth #32 (D7240). 
 
You asked the Plan to pre-approve the removal of an impacted tooth. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says that the removal of an impacted tooth (D7240) 
is not covered by the enrollee's dental benefits. 
 
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 requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of impacted tooth #32 (D7240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered 
by Medicare. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network skilled nursing facility 
(SNF) stay provided on July 1, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you weren't given an option between 
a private or shared room and were sent here due to a surgery from a leg break. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment per day, from days 21 to 100 for skilled nursing facility (SNF) services. You had a continued stay 
for 16 days, resulting in a $650 copayment ($50 x 16 days = $650). 
 
You have been asked to pay a $650 for a SNF stay. This item/service falls within the skilled nursing facility 
(SNF) services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network skilled nursing facility (SNF) 
stay provided on July 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 1, 2021, to March 31, 2021. 
 
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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. There is no indication that the 
enrollee had malnutrition and that the 4th alphanumeric character in the PDPM was correct. The partial 
adjustment to PDPM JEGF1 was appropriate. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from March 1, 2021, to March 
31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 22, 2020, to October 26, 2020. 
 
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 the DRG was updated.  
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 291. 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 not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned secondary 
diagnosis code. The documentation does not indicate that the diagnostic work-up and treatment ordered by the 
treating medical providers supported a diagnosis code J18.9 (pneumonia, unspecified organism). The decision 
to remove the secondary diagnosis code and adjust the DRG is upheld.  
 
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 to the enrollee from October 22, 2020, to October 26, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. The enrollee is 
hemodynamically stable. He is on an oral antibiotic for a toothache and will follow up with a dentist. His blood 
work was within normal range. He has no pain and is tolerating a regular diet. His weakness is improving. 
While the enrollee may benefit from additional multiple therapies, including physical and occupational therapy, 
the documentation does not reveal that the enrollee requires this therapy on an intensive IRF level. The 
enrollee's functional level does not require the ongoing intensity of an IRF, and his needs can safely and 
effectively be met at a lower 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee has not had a trial of at least 14-weeks 
of Inflectra or Avsola resulting in minimal clinical response to therapy and residual disease activity. The Plan 
says that there is no evidence that the enrollee has an intolerance or adverse event to Infelctra or Avsola. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Inflectra or Avsola before they will approve the requested drug. In this case, the patient has not tried and failed 
the required drugs. There is no documentation provided indicating that the Plans required drugs would likely 
be less effective and/or likely have adverse effects for the 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies provided on 
September 16, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that a new MDR was added with the proof of 
delivery signed by the patient. The Plan denied your request. The Plan says the date of service does not match 
the delivery/shipping date or the date the label was created. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, documentation shows the shipping date to 
have been September 9, 2022, and the delivery date shows to have been September 12, 2022. These dates do 
not match the date of service billed. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
continuous glucose monitor (CGM) supplies provided on September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 23, 2021, to October 29, 2021. 
 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 there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
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 190. 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 not supported by the medical records. Our physician reviewer found 
that the laboratory studies and treatment plan did not reflect the diagnosis of acute respiratory failure with 
hypoxia. The documentation does not indicate that the diagnostic work-up and treatment ordered by the 
treating medical providers supported a diagnosis code J96.01 (acute respiratory failure with hypoxia). In this 
case, the documentation does not consistently and completely support the assigned secondary diagnosis code. 
The decision to remove the secondary diagnosis code and adjust the DRG is upheld.  
 
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 to the enrollee from October 23, 2021, to October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg with stance flexion feature and 
other parts (L5611, L5845, L5964). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the patient has special needs for protection against 
unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by a standard prosthetic cover. Therefore, this prosthetic cover (L5964) 
exceeds the patient's medical needs. In terms of L5845 and L5611, they also exceed the enrollee's needs. The 
stance phase feature is included in the approved L5812, therefore the L5845 is also not medically necessary. 
The additional knee unit exceeds the patient's medical needs. The patient was approved for a complete 
prosthetic and the requested additional L5611 exceeds the patient's medical needs and is not medically 
necessary. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a new prosthetic leg with stance flexion feature and other parts (L5611, L5845, L5964).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided to 
the enrollee from May 26, 2022, to July 7, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the appropriate DRG for this case is 189 - 
pulmonary edema and respiratory failure. 
 
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 981. 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 not supported by the medical records. Our physician reviewer found 
that the procedure was performed inappropriately on a non-chronic pressure ulcer of undetermined stage. There 
is no Food and Drug Administration (FDA) indication for this of a skin substitute. The review has determined 
that the documentation did not support that the application of the skin substitute was medically necessary. The 
proper DRG assignment for the enrollee's LTACH inpatient stay is DRG 189.  
 
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 long term acute care hospital (LTACH) services provided to the enrollee from May 26, 2022, to July 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37232) provided on July 21, 2022. 
 
You asked the Plan to pay for the service. You say that this service was reported appropriately and is supported 
as billed. The Plan denied your request. The Plan says this service is not supported by the medical records 
provided. 
 
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 code 37232 is revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List 
separately in addition to code for primary procedure). 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report does not include documentation of 
revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty. This procedure code was not found in the procedure report and therefore, cannot be verified.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the revascularization (37232) provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 
77470, G6002, G6015). 
 
You asked the Plan to pre-approve radiation therapy. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says Medicare can only pay for medically 
necessary services, and without the specific documentation requirements, the medical necessity is 
unconfirmable. IMRT is not generally accepted for superficial skin cancers. Based on the additional 
information available, the request does not meet the Medicare or health plan coverage criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee will be prescribed 45-55 Gy in 25 fractions to the bilateral cheeks per 
the letter of appeal. However, there is no dosimetric rationale to support that IMRT is needed to spare any of 
these structures. IMRT is an external beam radiation technique used to improve the dose conformality. In 
general, IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the 
radiation dose distribution, and therefore minimize the dose to normal structures. For some skin cancers, IMRT 
is medically necessary and is the safest and most effective way to treat an enrollee. Examples would be skin 
cancers of the skull requiting circumferential targeting of radiation while avoiding the brain; advanced skin 
cancers with nodal involvement of perineural spread requiring nodal radiation or skull base radiation; 
previously irradiated cancers; or cancers that simply cannot be treated without exceeding tolerance to normal 
tissues.  The case records do not demonstrate any of these to apply. There is no description of the lesions (size, 
depth) and no dosimetric rationale for the need for IMRT. IMRT for the routine treatment of superficial skin 
cancers is not standard of care and the need for IMRT is not demonstrated with a plausible rationale for need, 
or dosimetric rationale (which is required by ASTRO model policy for demonstrating need for cases for which 
IMRT is not standard). The decision is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 77470, G6002, G6015).