Persius/hicric huggingface dataset:
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's needs cannot be met at a 
lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
LTACH services do not meet the requirements for approval. 
 
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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services including oxygen weaning that can be safely provided by the current facility 
until appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to an LTACH is not medically necessary at 
this time as it would not be clinically advantageous. Transfer to a lower level of care may be considered when 
treatment has completed. 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 pay for inpatient hospital services provided to the enrollee from 
March 1, 2021, to March 8, 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 payment of DRG 190 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 DRG 190 (CHRONIC OBSTRUCTIVE 
PULMONARY DISEASE WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was treated in the hospital for chronic obstructive pulmonary disease 
(COPD) exacerbation. In the emergency department, he was noted to be short of breath, and required 3L 
oxygen support via nasal cannula with 90-96% SpO2 and able to speak full sentences, without work of 
breathing or accessory muscle use or diaphoresis. He was later weaned off oxygen support before discharge. 
The most appropriate DRG, therefore, would be 191 as DRG 190 is not sufficiently supported in the provided 
documentation without evidence of acute respiratory failure as criteria for this diagnosis was not met as noted 
in the documentation.   
 
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 March 1, 2021, to March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from October 5, 2021, to 
October 14, 2021, as billed with Diagnosis Related Group (DRG) 480. 
 
You asked the Plan to pay for inpatient care billed with DRG 480. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 480 is not supported as metabolic encephalopathy (G93.41) and therefore major complications or comorbidities (MCC) 
are not supported in the medical record. The Plan argues that DRG 481 is more appropriate in this case. 
 
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. DRG 480 is described as hip and femur procedures except 
major joint with major complications and comorbidities. 
 
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 inpatient care billed with DRG 480. Our 
reviewer says that the DRG is not supported as billed. Our physician reviewer found that the enrollee was 
brought to the hospital after she had a mechanical call and was found to have a left intertrochanteric hip 
fracture. After shed was cleared for surgery, she was taken to the operating room and had a gamma nail. 
Postop, the enrollee was very confused, lethargic, and was medicated for pain. Her opiates were discontinued, 
and her mental status improved. A day later her mental status was again very lethargic, and was found to have 
urinary tract infection which was treated. Upon discharge, the enrollee will be continued on medications for the 
infection, and after medications her condition slowly improved. She was discharged to a subacute facility. The 
review has determined that the medical records did not support the billing of major comorbidities and 
complications, as billed in this case as metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 480 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from October 5, 2021, to October 14, 
2021, as billed with Diagnosis Related Group (DRG) 480.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on October 5, 
2021. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The available medical records do not discuss 
the item at issue. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) 
provided on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Debridement of nail(s) by any method(s) (11720) 
provided on December 1, 2021. 
 
You asked the Plan to pay for code 11720. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 11720 
is a column II code to column I code 11056. 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 the Debridement of nail(s) by any method(s) (11720) provided 
on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the abdomen (74018) provided on November 15, 
2021. 
 
You asked the Plan to pay for the x-ray of the abdomen. You say that you would like reconsideration because 
this service was rendered in the appropriate place of service. The Plan denied your request. The Plan says this 
claim was billed with an incorrect POS code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 74018 is not supported in the record. Specifically, the record indicates that the enrollee 
was registered inpatient on the billed date of service. This claim was not billed with the inpatient POS code. 
Based on this information, we decided that Medicare rules for coverage of the x-ray of the abdomen have not 
been met. Therefore, we decided that the Plan does not have to pay for the x-ray of the abdomen (74018) 
provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percutaneous Image-Guided Lumbar Decompression 
(PILD) procedure (0275), provided on March 17, 2020. 
 
You asked the Plan to pay for the PILD procedure. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no documentation provided to support the enrollee was participating 
in an approved 
clinical study for evidence development. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered for enrollee's in an 
approved clinical study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PILD procedure have not been met. Therefore, we decided that the Plan does not have to pay for the Percutaneous Image-Guided Lumbar Decompression (PILD) procedure (0275), provided on March 17, 
2020.
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 you need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care 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 you are a 63-year-old male who was admitted to the acute care hospital with 
abscess of the sacrum requiring wound care including antibiotics, surgical flap closure of sacral wound. Recent 
notes describe the patient as improving with healing wound, good circulation, and no longer requiring complex 
wound care or antibiotics. You appear to be improving and should only require short-term additional acute care 
services that can be safely provided by the current facility until appropriate for a lower level of care. You do 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that you require that are not already available and covered at the current facility. Transfer to 
LTACH is not medically necessary at this time as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed. 
 
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 acute inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that inpatient hospital care is medically 
necessary in this case. The Plan denied your request. The Plan says the enrollee's condition is not severe 
enough to warrant an inpatient hospital admission. An observation setting is sufficient in this case. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient services are met in this case.  Our physician reviewer found that the record sent by the provider indicates that the enrollee presented to the 
hospital for a scheduled rectal surgery (transanal excision of rectal tumor). The operative note states that, the 
dissection of the tumor was extensive and complicated and therefore, the surgeon chose to admit the patient 
overnight for observation given her advanced age and comorbidities. She did well overnight and was 
discharged home the following day. This surgery is not on the inpatient only list. There was no indication for 
inpatient level of care services. The enrollee did not require or receive any inpatient diagnostic studies or 
therapeutic interventions. The review has determined that the record does not show that at the time the 
admitting physician reasonably expected that the enrollees necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve acute inpatient hospital services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. 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 not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on November 24, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were told that your copayment 
would be $198. The Plan denied your request. The Plan says this claim was billed with a place of treatment of 
outpatient hospital, which means the correct copay applied per the members 2021 EOC, page 73 and the 
Customer Service Representative advised the member that the outpatient hospital copay would be $275. 
 
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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies, Outpatient Hospital.  
 
You have been asked to pay a $275 copayment for the MRI. The MRI falls within the outpatient diagnostic tests and therapeutic services and supplies, Outpatient Hospital 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 the MRI provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 
10, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration 
because the Place of Service (POS) code billed is correct. The Plan denied your request. The Plan says this 
claim was not billed with the correct POS code. 
 
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 99233 is 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 find that CPT code 99233 is not supported in the record. Specifically, the record indicates that the enrollee 
was outpatient on the billed date of service. It is not appropriate to bill an inpatient CPT code and inpatient 
POS code on an outpatient claim. Based on this information, we decided that Medicare rules for coverage of 
the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
the subsequent hospital care (99233) provided on October 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of zoledronic acid or a history of an osteoporotic fracture before they will approve the requested drug. In 
this case, the patient does not have an osteoporotic fracture and has not tried and failed the required drug. There 
is no documentation provided indicating that the plans required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 patient is stable and ready for 
transfer to an LTACH The Plan denied your request. The Plan says the patient can be managed at the current 
facility 
 
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 the patient was admitted with complications from metastatic gastrinoma.  The record 
indicates that the patient has ongoing complications such that he is not clinically stable and requires ongoing 
acute care services.   The patient continues to receive acute care services, and these have not been denied.  The 
medical record does not indicate that the patient requires services that he is not currently receiving but that 
would be available at the LTACH 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 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.