Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supervision of hyperbaric oxygen therapy (procedure code 99183) provided to the enrollee on February 3, 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 99183 (1 unit) 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 99183 is "Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session." 

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 medical documentation does not fully support the use of procedure code 99183. The limited information documented simply states the visit was 20 minutes. There are no details on the actual supervision, or the amount of time the patient spent in the chamber. There is no current patient status of the patient while in the chamber.

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 supervision of hyperbaric oxygen therapy (procedure code 99183) provided to the enrollee on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary, and he is interested in continuing aggressive therapy for physical therapy and occupational therapy. The Plan denied your request. The Plan says authorization denied because the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF).

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 specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF). 

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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that the enrollee needs SNF services. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our physician reviewer found 
daily skilled services are not necessary. Our physician reviewer found that the medical records do not 
document that you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that you need skilled nursing services in order to do basic life 
tasks. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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. Our physician reviewer found 
daily skilled services are not necessary. Our physician reviewer found that the medical records do not 
document that you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care provided from June 10, 2021, to 
June 18, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pre-approve inpatient care as billed with DRG 871. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
The Plan argues that DRG 602 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. 
 
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 care as billed with DRG 871. 
Our reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found that the enrollee presented to the emergency 
department on June 10, 2021, with a three-month history of swelling of the right ring finger. A course of oral 
antibiotics had been completed a few months earlier. The evaluation found the enrollee to be alert. There was 
swelling of the right ring finger with purulent discharge. The enrollee was started on intravenous (IV) 
antibiotics and admitted. During the hospitalization, it was found that the enrollee had deep vein thrombosis 
(DVT) of the lower extremity, for which anticoagulation was started. The IV antibiotics were discontinued on 
June 17, 2021, and the enrollee was discharged a day later with home medication for continued treatment of the 
DVT. This review has determined that there was no clinical or laboratory evidence of sepsis. The medical 
records did not support the billing of sepsis, unspecified organism (A41.9) for this inpatient stay. 
 
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 as billed with DRG 871 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient hospital care provided from June 10, 2021, to June 
18, 2021, as billed with Diagnosis Related Group (DRG) 871.
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 the medical criteria for a LTACH admission has 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 the enrollee can then be transferred/discharged to a lower level of care for any 
ongoing LTACH 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue 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 a capsule endoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's diarrheal illness for which wireless capsule endoscopy has been 
recommended has resolved per provided charting. In addition, both colonoscopy and small bowel radiography 
have proved unremarkable. 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
February 1, 2021, to February 11, 2021. 
 
You asked the Plan to pay for the SNF services. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. In this case, the SNF services are not payable when the RN 
assessment coordinator has not signed, and thereby certified, that the assessment is complete. The file shows 
that item Z0500 of the MDS has not been signed. We cannot validate that the MDS assessment was completed 
timely without a signature. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) services provided from February 1, 2021, to February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multi-level fusion surgery (extreme lateral interbody 
fusion or XLIF). 
 
You asked the Plan to pre-approve multi-level fusion surgery. You say that you are tired of taking pain pills 
and not being able to do anything. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because this is considered a non-standard treatment and is experimental/investigational. 
 
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 multi-level fusion surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are limited large-scale, long-term studies showing the safety and 
efficacy of the requested surgery in your clinical setting. There is no compelling rationale or extenuating 
circumstance noted to support the necessity of this procedure as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multi-level fusion surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve multi-level fusion surgery (extreme lateral interbody fusion or XLIF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of bilateral knee pain due to osteoarthritis. The enrollee has not trialed one 
viscosupplemental treatment such as Orthovisc, Synvisc or Synvisc-One. The documentation does not outline 
contraindications or reasons these medications were not considered. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with supervision and no assistive device and is modified independent for transfers. 
Provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. You do not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the home with home health care or in a long-term care facility 
on a part time basis are not 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar/interspinous device. 
 
You asked the Plan to pre-approve an interlaminar/interspinous device. You say that the records provided 
support the need for the requested procedure. The Plan denied your request. The Plan says the data is limited 
regarding safety and effectiveness of the requested procedure. 
 
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 an interlaminar/interspinous device. 
Our reviewer says that an interlaminar/interspinous device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process devices remain experimental for use 
in spinal surgery. More research is needed. 
 
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 interlaminar/interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interlaminar/interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracorporeal shock wave therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical value has not been demonstrated in peer-reviewed literature. 
 
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 requested services. Our physician 
reviewer found that it is well established that this enrollee has been suffering with ulcerations to the left foot for 
greater than nine months. They have undergone routine debridement, Unna boots dressings, and wound VAC. 
A dermaPACE system, which is a low energy acoustic pressure shockwave device for the treatment of wounds 
has been requested. Shockwave therapy for the treatment of wounds is still in the experimental stage. Each of 
the medical studies that have been reviewed advise that further, more extensive studies are necessary in order 
to confirm that this treatment is extremely efficacious. Essentially, shockwave therapy is still considered 
experimental for the treatment of wounds. Therefore, the requested shockwave therapy cannot be considered 
medically reasonable or necessary for the enrollee at this time. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve extracorporeal shock wave therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lynparza tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lynparza tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) therapy. 
 
You asked the Plan to pre-approve TMS therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TMS therapy is reasonable and necessary when it is 
furnished in accordance with the accepted standards of medical practice, when it is furnished in a setting 
appropriate to the patients medical needs and condition, when it meets but does not exceed the patients 
medical need and when it is ordered and furnished by qualified personnel. 
 
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 TMS therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this enrollee does not have an 
indication for the requested Transcranial Magnetic Stimulation (TMS). This enrollee does not meet the LCD 
(L37088) requirement for Transcranial Magnetic Stimulation (TMS) in the treatment of this enrollee as he does 
not meet the criteria for the use of Transcranial Magnetic Stimulation (TMS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) therapy.
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 you do not feel you will get the best rehabilitation in 
SNF. The Plan denied your request. The Plan says rules for IRF care have 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 IRF admission and services.