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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 20, 2020, 
through July 22, 20202 and billed with Diagnosis Related Group (DRG) 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that you would like 
reconsideration because the documentation supports the DRG billed. The Plan denied your request. The Plan 
says the documentation submitted does not support the DRG billed. 
 
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 871 and diagnosis codes A41.9 and G93.41. 
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 billed with 
DRG 871. Our reviewer says that the diagnoses of metabolic encephalopathy and sepsis with DRG 871 are not 
supported by the documentation. Our physician reviewer found there was insufficient documentation showing 
the enrollee had a rise of 2 or more SOFA score points and no evidence of neurological signs suggestive of 
encephalopathy after initial treatment in the ED to justify encephalopathy and no signs of organ damage from a 
systemic infection that would meet sepsis criteria.  
 
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 20, 2020, through July 22, 20202 and billed with Diagnosis 
Related Group (DRG) 871.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from September 10, 2021, 
to September 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical notes support the services. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. The records show that the enrollee received 25 minutes of care on each date of service at 
issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the critical care services provided from September 10, 2021, 
to September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on December 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 76705 was billed with code 93976. We find that CPT code 76705 may be eligible 
for payment when billed with this code pair. The claim does not show that the code at issue was billed with a 
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
abdominal ultrasound provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that a bone growth stimulator is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for a bone growth 
stimulator are not met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist 
under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or 
more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-
approve a bone growth stimulator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for upper endoscopic procedures (00731) provided on 
June 1, 2021. 
 
You asked the Plan to pay for the anesthesia for upper endoscopic procedures (00731). You say that you are an 
anesthesia provider and bill separately using modifiers per Medicare guidelines. You say that the medical 
records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan 
says that this service is included in payment for an inclusive service in an esophago-gastric duodenoscopy 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the anesthesia is considered inclusive to another service billed. 
The Plan did not submit a claim form supporting another service was billed for CPT code 00731 to be 
considered inclusive and not separately payable. It is the burden of the Health Plan to substantiate their denial 
with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for the anesthesia for upper endoscopic procedures (00731) provided on June 1, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are 
medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not 
covered by Medicare for lymphedema. The Plan notes that compression stockings are available through 
the over-the-counter benefit and free for the member based on quarterly allotment. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are 
non-covered for treatment of lymphedema without the presence of ulcers. Although this item may be 
appropriate, the required criteria for coverage are not met. Therefore, we decided that the Plan does not have to 
pre-approve compression stockings identified with code A6531.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on June 19, 2021. 
 
You asked the Plan to pay for the billed services. You say that the coding done was at best. The Plan denied 
your request. The Plan says the information does not support this level of service. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room for pain in the left hip. The enrollee was treated for a hip dislocation. The 
records do not show that the enrollees condition posed an immediate significant threat to life or physiologic 
function. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit provided on June 19, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and 
insulin. The enrollee had stable vital signs and continued dialysis. He was at a standby assist to independent 
level for functional mobility including gait to 300 feet. The enrollee does not require skilled nursing or therapy 
services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of drug-eluting implant (0356T) provided on 
August 10, 2021. 
 
You asked the Plan to pay for insertion of drug-eluting implant. You say that this service was necessary. The 
Plan denied your request. The Plan says there is insufficient documentation to support payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of insertion of drug-eluting implant 
(0356T) provided on August 10, 2021. have been met. Specifically, medical records were not provided to support this service as billed. Documentation shows that the Plan has made multiple attempts to obtain the 
necessary medical records, but these were not provided to the Plan. Therefore, we decided that the Plan does 
not have to pay for insertion of drug-eluting implant (0356T) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on August 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of renal cell 
carcinoma with metastases. The oncologist notes that aggressive treatments and surgical resection would be 
deferred. Outpatient follow-up for starting targeted therapy with immunotherapy was planned. The oncologist 
notes that aggressive treatments and surgical resection would be deferred. Outpatient follow-up for starting 
targeted therapy with immunotherapy was planned. The testing was therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 testing rendered on August 29, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. Your needs are 
currently being met in the IRF and can continue to be met until you are prepared for discharge to the home or 
community setting. There are no extenuating factors that require a transfer at this time to a 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found This 95-year-old male was being treated for spinal stenosis, lumbar region with 
neurogenic claudication. He presented with pain in the foot. The pain is described as pain started in lower 
back, but now pain is in the feet mostly at night. The pain is aching, burning, and getting worse. There are no 
current objective examinations or diagnostic studies provided for review. However, current evidence based 
medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure 
over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. 
Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. There are no magnetic resonance imaging studies provided for review to 
demonstrate pathology at the requested surgical level of L4-5. FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There no 
discussion of spinal instability on flexion/extension films.There is no discussion of scoliosis of the lumbar 
spine and/or documentation of the Cobb angle. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the request for Vertiflex Superion interspinous device at L4-5 is not medically reasonable or 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary. 
The Plan denied your request. The Plan says the requested item is considered experimental/investigational for 
the enrollee's condition. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 77-year-old woman with recurrent congestive heart failure (CHF). At 
issue is the medical appropriateness and necessity of implantation of the wireless pulmonary artery pressure 
monitoring system CardioMEMS for management of CHF in this patient. The CardioMEMS device was 
approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF.  
 
 The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided on July 28, 
2020, through July 31, 2020 and billed with Patient Driven Payment Model (PDPM) score KAPE1 for 4 days. 
 
You asked the Plan to pay for the SNF services billed with PDPM score KAPE1 for 4 days. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation submitted does not support the PDPM billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
 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 SNF services billed with PDPM score  
KAPE1 for 4 days. Our reviewer says that only documentation for the collection dates of July 28, 2020, July 
29, 2020 and July 30, 2020 can be considered to support the GG item coding. The record does support every 
item with the exception of the MDS item: GG0130B, Oral Hygiene. Our physician reviewer found the 
documentation does not support that the enrollee required supervision or touching assistance (ADL score of 4) 
for oral hygiene for the dates July 28, 2020, through July 30, 2020. 
 
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 services billed with PDPM score  KAPE1 for 4 days have not been 
met. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services 
provided on July 28, 2020, through July 31, 2020 and billed with Patient Driven Payment Model (PDPM) score 
KAPE1 for 4 days.