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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility services 
you are requesting 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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF.  Specifically, you have not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your needs can 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on February 
12, 2022, to February 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you were told authorization was not needed. 
The Plan denied your request. The Plan says utilization of network providers and authorization for certain 
services are required. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the outpatient mental health services provided on February 12, 
2022, to February 26, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization, open or percutaneous, 
tibial/peroneal artery, unilateral (37228). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing for coverage. date of 
service has already passed. The Plan denied your request. The Plan says the records do not support the need for 
this service. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was seen in the hospital July 20, 2022. At the time the enrollee was 
complaining of leg pain and was identified to have a GI bleed that according to the provided needed to be 
addressed prior to consideration of angiography and possible intervention.  The enrollee was seen in the office 
7 days later, on July 27, 2022. There is no mention of the GI bleed at that visit and no documentation that the 
GI Bleed issue has been resolved. There is, however, documentation of an angiogram performed less than one 
year prior, presumably as the enrollee was symptomatic at that time, that demonstrated no significant lower 
extremity arterial occlusive disease. In summary, considering palpable pedal pulses, no sign of limb threat, and 
history of GI bleed the week prior that remains unresolved, unable to overturn health plan determination. The 
documentation does not meet coverage criteria and does not support the medical necessity of the treatment in 
question. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovascular revascularization, open or percutaneous, tibial/peroneal artery, 
unilateral (37228).
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 a LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a LTACH 
admission. 
 
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 you were admitted to the hospital with sepsis in the setting of an infected dialysis 
access graft. The record indicates that you are improving but still require acute care services before 
transitioning to a lower level of care. You continue to receive acute care services which have not been denied. 
The medical record does not indicate that you require services that are not currently being received but that 
would be available at the LTACH facility. The elements of the coverage rules 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this level of care. The Plan denied your 
request. The Plan says that the coverage criteria has not been met. 
 
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 that there are hospital complications documented as medically stable thus would not 
be expected to require continued inpatient hospitalization during rehabilitation. 
 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you feel that this is required to prevent 
hospitalization and death. The Plan denied your request. The Plan says the enrollee does not need a ventilator. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 64486) provided to the 
enrollee on May 4, 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 64486-RT-59 remains 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 code 64486 is "Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when 
performed)." 
 
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 the procedure report do not include documentation to support the block was for post operative pain management to be performed at the 
request of the operating provider, and the anesthesia is not dependent of the block. This documentation is not 
include in procedure report and therefore modifier -59 cannot be verified as a separate procedure.  
 
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 surgical services (procedure code 64486) provided to the enrollee on May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical spinal fusion and artificial disc surgery (22856, 
22551, 22552, 22853, 22845, 20936). 
 
You asked the Plan to pre-approve cervical spinal fusion and artificial disc surgery. You say that you need 
these procedures to be performed together. The Plan denied your request. The Plan says these procedures 
cannot be approved together. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical disc replacement (CDR) is considered 
investigational for the combined use of an artificial cervical disc and fusion.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cervical spinal fusion and artificial disc surgery have not been met. These services are considered 
investigational when performed together. Therefore, we decided that the Plan does not have to pre-approve 
cervical spinal fusion and artificial disc surgery (22856, 22551, 22552, 22853, 22845, 20936).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you cannot afford to pay this. The Plan denied 
your request. The Plan says you must get your care from network providers. 
 
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 laboratory services provided on July 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound provided on 
June 13, 2022. 
 
You asked the Plan to waive the copayment for the retroperitoneal ultrasound. You say that the test was 
medically necessary. 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 
$131.43 copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $131.43 copayment for the retroperitoneal ultrasound. This item/service falls 
within the radiological diagnostic services, not including x-rays 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. The allowed amount for the ultrasound is $131.43. 
Since this is less than the $165 copayment per the EOC, you are only responsible for the lesser amount. 
Therefore, we decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound 
provided on June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
May 23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not be 
responsible to pay this. 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 $300 
copayment for each in-network Medicare-covered visit to an ambulatory hospital facility.  
 
 
 
 
 
 
 You have been asked to pay a $300 copayment for a diagnostic colonoscopy. This item/service falls within the 
ambulatory surgical center 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 a diagnostic 
colonoscopy provided on May 23, 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 you need these services. The Plan denied your 
request. The Plan says the needed services can be provided safely in another setting. 
 
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 was admitted for surgical management of an infected artificial hip joint. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs.  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to a new acute care facility for the enrollee. 
 
You asked the Plan to pre-approve the transfer. You say that this is medically necessary. The Plan denied your 
request. The Plan says the second facility is not a higher level of care, and the current facility is able to 
appropriately manage care. 
 
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 transfer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the inpatient admission was not medically necessary for this beneficiary. Inpatient care is necessary 
when the patients signs and symptoms and general medical condition can only be managed safely in an acute 
inpatient setting, when the enrollee requires diagnostic studies in an inpatient setting, or if it is medically 
necessary for the enrollee to remain in the acute inpatient setting. The documentation does not support the 
medical necessity for a transfer to another inpatient hospital. The plan of care for this member is to receive 
palliative/hospice medical care. She can continue to receive further care at the current acute care hospital or a 
lower level of care when deemed appropriate. Transfer to another acute inpatient hospital 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 transfer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transfer to a new acute care facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for travel. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that the oxygen supplier refused to 
coordinate any oxygen needs and believes they are no longer responsible. The Plan denied your request. The 
Plan says the requested provider is out-of-network and Medicare will only pay one supplier to provide oxygen 
during any one-rental month. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will pay only one supplier to provide 
oxygen during any one-rental month. 
 
We looked at the file and Medicare rules. The enrollee already has rented oxygen equipment; therefore, 
Medicare will not cover rented equipment from a second supplier during the same month. The enrollees 
oxygen supplier is responsible for furnishing the needed equipment. Please contact the Plan for more 
information about the enrollees treatment options. Based on this information, we decided that Medicare rules 
for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator for travel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 16, 2021, to July 
19, 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. You say that the 
medical records support the billed principal diagnosis code. The Plan denied your request. The Plan says the 
services as billed are not supported in the documentation. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism 
 
. 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 documentation does not support the billed principal diagnosis code. 
Our physician reviewer found the enrollee is an 89-year-old female who presented to the hospital with a urinary 
tract infection. She had fever, had normal platelets, normal bilirubin, was alert and oriented, had high blood 
pressure, was tolerating room air, and elevated creatine (chronic). Blood cultures showed contamination or no 
growth. Based on the fact that there was no clear evidence of systemic infection or organ dysfunction related to 
a systemic infection, the Sepsis criteria was not met, and the medical records do not support principal diagnosis 
code A41.9.  
 
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 16, 2021, to July 19, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing (SPECT). 
 
You asked the Plan to pre-approve . You say that you disagree with the denial. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SPECT is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has shortness of breath. A 
treadmill stress test was performed and interpreted as positive for ischemia. As such, there is no evidence 
provided that would support the need for radionuclide stress testing. There is insufficient documentation to 
support the medical necessity for the requested radionuclide stress 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radionuclide stress testing (SPECT).