Persius/hicric huggingface dataset:
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 services are necessary to help you build up your 
strength, balance and speech. The Plan denied your request. The Plan says the services you need can be 
provided safely in another setting such as a skilled nursing facility or home with health services. 
 
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 you do not require extensive therapy services. While you may benefit from physical 
and occupational therapy, your rehab needs can be provided in a lower intensity and alternate setting such as in 
a skilled nursing facility or at home with services. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and artery study provided on August 22, 
2022. 
 
You asked the Plan to pay for the office visit and artery study. You say that records show the provider is a 
network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and 
artery study provided on August 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroscopy, knee, surgical; with meniscectomy 
(medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage 
(chondroplasty), same or separate compartment(s), when performed (29881). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you feel this surgery is necessary to 
potentially repair a microtear in your meniscus. The Plan denied your request. The Plan says the records 
provided do not support that the Plans criterion has been met. 
 
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 this enrollee was being treated for other meniscus derangements, other medial 
meniscus, right knee. The enrollee presented with symptoms are essentially the same as what they were 
previously and are always medial-sided. They are worse with activity and better with rest. The enrollee notes 
occasional catching-type symptoms. The exam reveals medial-sided pain in deep flexion. There is medial joint line tenderness. There is pain with McMurrays. X-rays were noted to show some degenerative changes in the 
knee throughout, but in the lateral compartment and in the patellofemoral compartment particular they are 
fairly minimal with just some mild osteophytosis but preservation of the joint space; on the medial side he has 
loss of normal joint space with a little bit of sclerosis, however, there is not a significant amount of 
osteophytosis. However, there is clear diagnostic imaging evidence of degenerative joint disease/osteoarthritis. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested arthroscopy of the knee with 
meniscectomy including debridement/shaving of articular cartilage (chondroplasty), in this case, 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including 
any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate 
compartment(s), when performed (29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SoClean sanitizing device. 
 
You asked the Plan to pre-approve sanitizing device. You say that this is needed to prevent bacteria buildup. 
The Plan denied your request. The Plan says this device is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a SoClean sanitizing device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
February 2, 2023. 
 
You asked the Plan to pre-approve SNF care after February 2, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued 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 SNF care after February 2, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. 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 skilled nursing facility 
(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 SNF care after February 2, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy services provided on August 
23, 2022, by an OON provider. 
 
You asked the Plan to pay for esophagogastroduodenoscopy services. You say that you were told no 
authorization would be required. The Plan denied your request. The Plan says the enrollee must receive care 
from a network provider. 
 
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 esophagogastroduodenoscopy services provided 
on August 23, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in desperate need of physical therapy and 
have no way to do it at home. The Plan denied your request. The Plan says the request for an IRF admission is 
not medically necessary. 
 
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 the documentation does not support the necessity for admission to an IRF due to 
the lack of medical or rehabilitation complexity, and no rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, your needs can be provided in a lower 
intensity and an alternate setting such as in an 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 the IRF admission and services.
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 enrollee is able to withstand at least three hours 
of therapy a day and is highly motivated. You say you would like the enrollee to have at least two weeks in 
acute rehab to return to their prior level of function. The Plan denied your request. The Plan says the criteria for 
admission to an IRF 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 19, 2021, to 
August 2, 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 these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical records provided. 
 
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 sepsis due to enterococcus (A41.81). 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 this diagnosis is not supported in the medical record. Our physician reviewer found that 
the enrollee presented to the facility on July 19, 2021, with increased malaise and flank pain. Past medical 
history included benign prostatic hyperplasia, diabetes mellitus, hyperlipidemia, hypertension and chronic 
kidney disease (CKD) stage 3. Initial vital signs on presentation revealed a temperature of 98.6, a heart rate of 
116, a respiratory rate of 25, blood pressure of 100/64, and oxygen saturation (SpO2) of 96%. The enrollee was 
noted to have a positive urine culture and was treated for a complicated urinary tract infection. In this case, 
there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did 
not support sepsis due to enterococcus (A41.81).  
 
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 19, 2021, to August 2, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37228. We decided that the Plan does not have to pay for 36247.  
 
You asked the Plan to pay for surgical services (procedure code 36247, 37228) rendered to the enrollee on 
December 16, 2021.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 37228.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 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 for CPT 37228 (revascularization, endovascular, open 
or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty). Our reviewer 
says that this codes for balloon angioplasty of a tibial artery.  There is satisfactory documentation that the 
posterior tibial artery was angioplastied with improved angiographic result. There is a description of the degree 
of stenosis in the artery that was treated prior to angioplasty as well.  While the description of the posterior 
tibial artery following angioplasty could have been documented in more detail, the description meets the 
minimal threshold of documentation to justify that the work indicated by code 37228 was performed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
37228.  
 
We also decided that the Plan does not have to pay for 36247. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
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 for CPT 36247 (s). Our reviewer says that this codes 
for second or third order catheterization.  Intervention codes for lower extremities (including the above code 
37228) are maximally bundled and include associated catheterization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36247 have not been met. Therefore, we decided that the Plan does not have to 
pay for 36247. 
 
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 an acrylic sock (L5629) and suction socket (L5647) for 
a preparatory lower limb prosthesis. 
 
You asked the Plan to pre-approve acrylic sock and suction socket. You say that you are appealing this denial. 
The Plan denied your request. The Plan says these prosthetic components are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that acrylic socks and suction sockets are not covered 
for preparatory prostheses.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of acrylic sock and suction socket have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acrylic sock (L5629) and suction socket (L5647) for a preparatory lower limb 
prosthesis.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan for needle biopsy (77012). 
 
You asked the Plan to pre-approve a CT scan for needle biopsy. The Plan denied your request. The Plan says 
that the enrollee has a loss of smell attributed to a past brain injury, and a nerve block (stellate ganglion) for 
loss of smell is considered investigational. The Plan also says it is not clinically proven, and it is not considered 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 CT scan for needle biopsy. Our 
reviewer says that the requested CT scan for needle biopsy is considered medically reasonable and necessary in 
this case. Our physician reviewer found the use of CT as a localizing tool for the placement of the needle to 
perform the block is absolutely medically necessary in order to ensure the correct anatomic region in the neck 
is targeted and the needle location confirmed prior to the injection. 
 
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 CT scan for needle biopsy have been met. Therefore, we decided that the Plan 
has to pre-approve a computed tomography (CT) scan for needle biopsy (77012).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service (POS). 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. In this case, the records do not show that it is appropriate to bill POS 
54 (Intermediate Care Facility/Individuals with Intellectual Disabilities) for the provided services. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, 
this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a 
laboratory setting. Therefore, we decided that the Plan does not have to pay for the services provided on 
September 1, 2022.