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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
was admitted with septic shock and diverticulitis with perforation. The enrollee continues to receive acute care 
services, and these have not been denied. The record indicates that the enrollee requires ongoing acute care 
services including antibiotics and total parenteral nutrition. The medical record does not indicate that the 
enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular lab testing provided on April 30, 2021. 
 
You asked the Plan to pay for the testing services. You say that medical necessity is reflected in the medical 
records. The Plan denied your request. The Plan says the testing is considered unproven. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records show that molecular urinary tract infection (UTI) testing was 
ordered. In this case, there were insufficient medical records from the treating physician to show that the testing 
was ordered due to signs and symptoms of a specific medical problem. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular lab testing 
provided on April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three single power wheelchair with one power 
option and related accessories. 
 
You asked the Plan to pre-approve a group three single power wheelchair with one power option and related 
accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the 
member does not have medical need for single power option included with K0856 group 3 power wheelchair. 
E2311 is not medically needed as there is no need to control more than two power options through the joystick. 
E2300 Seat Elevator does not serve a medical purpose and is never covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 requested items. Our reviewer says that these items are not 
medically necessary. Our physician reviewer found that the records do not document the patient is high risk for 
skin breakdown, requires urinary bladder self-catherization or has increased muscle tone or spasticity to meet 
criteria for the single power option and power tilt. As the patient does not meet criteria for the requested group 
3 power wheelchair with a single power option, none of the requested accessories are covered. 
 
The file does not show that you are at high risk for skin breakdown, requires urinary bladder self-catherization 
or has increased muscle tone or spasticity. Therefore, we decided that the Plan does not have to pre-approve a 
group three single power wheelchair with one power option and related accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Eliquis.  
 
Benefits for this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab 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 lab services provided on July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of face wrinkles (15828). 
 
You asked the Plan to pre-approve the removal of face wrinkles. You say that this is necessary based on the 
enrollee's history. The Plan denied your request. The Plan says these services are considered medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. The requested services are not for the diagnosis or treatment of 
illness or injury. Based on this information, we decided that Medicare rules for coverage of the removal of face 
wrinkles have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of 
face wrinkles (15828).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 17, 2021, through 
January 21, 2021 with the reported secondary diagnosis code N30.00, acute cystitis without hematuria. 
 
You asked the Plan to pay for inpatient services provided from January 17, 2021, through January 21, 2021 
with the reported secondary diagnosis code N30.00, acute cystitis without hematuria. You say that the 
diagnosis was supported based on physician documentation, clinical findings, treatment provided, and coding 
guidelines. The Plan denied your request. The Plan says there is no documentation of urinary tract symptoms in 
the medical record. Therefore, it is concluded that the urine culture results stem from asymptomatic bacteriuria 
and not from an acute infection. In current clinical practice patients who have bacteria in the urine, but no 
physical symptoms, are not considered truly infected and do not require treatment except in pregnancy and 
renal transplant. Therefore, there was insufficient clinical evidence to validate the diagnosis. 
 
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 code N30.00 acute cystitis without hematuria. 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 services provided from  
January 17, 2021, through January 21, 2021 with the reported secondary diagnosis code N30.00, acute cystitis 
without hematuria. Our reviewer says that the documentation does not support that the inpatient care is payable 
as billed. Our physician reviewer found that the enrollee is a 92-year-old female who was admitted to the 
hospital following a mechanical fall and Le Fort I fracture. Acute cystitis was included as a secondary 
diagnosis. The enrollee had not reported any symptoms of dysuria, was alert and oriented, did not have flank 
plan, abdominal pain, or nausea, and was afebrile without leukocytosis. Urine culture showed e. coli was 
present, however, the provided documentation concluded that the urine culture results stem from asymptomatic 
bacteriuria and not from an acute infection based on the whole clinical picture. Therefore, the provided 
documentation does not support the diagnosis of acute cystitis. Bacteriuria would be a more appropriate 
secondary diagnosis for this admission.  
 
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 services provided from January 17, 2021, through January 21, 2021 with the reported secondary 
diagnosis code N30.00, acute cystitis without hematuria.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical arthroscopy of the knee (29873, 29879) provided 
on November 24, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a knee arthroscopy. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
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 a surgical arthroscopy of the knee (29873, 29879) 
provided on November 24, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services rendered on April 21, 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 procedure code 11045 is 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 11045 is debridement, subcutaneous tissue (includes 
epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to 
code for primary procedure). 
 
We find that CPT code 11045 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 debridement services rendered on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 31, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
 
 
 
 
 We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on October 18, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on October 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a targeted genomic sequence analysis panel. 
 
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 that the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genomic sequence analysis 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 are medically necessary. Our physician reviewer found the enrollee has several reasons for abnormal 
blood counts, including myelodysplastic syndrome and plasma cell neoplasm. He previously underwent next-
generation sequencing panel testing in November of 2021. On January 5, 2022 there is documented concern for 
smoldering multiple myeloma. There is documented concern for myeloproliferative neoplasm, and the need for 
risk stratification and monitoring. The testing is 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 been met. Therefore, we decided that the Plan has to pay for 
a targeted genomic sequence analysis panel.  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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you live alone and really need the this to be able 
to get around, you can hardly walk without them. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a urinary tract 
infection and gastrointestinal bleeding. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prodigy test strips, Prodigy control solution and Lancet 
TruePlus 33G Twist lancets, provided on March 25, 2020. 
 
You asked the Plan to pay for Prodigy test strips, Prodigy control solution and Lancet TruePlus 33G Twist 
lancets. You say that the items are medically necessary. The Plan denied your request. The Plan says the 
preferred brand must be used for diabetic services and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Prodigy test strips, Prodigy control solution and Lancet TruePlus 33G Twist lancets have not been 
met. Specifically, there was no documentation submitted indicating the requested items were medically 
necessary over the Plan's preferred brand. Therefore, we decided that the Plan does not have to pay for the 
prodigy test strips, Prodigy control solution and Lancet TruePlus 33G Twist lancets, provided on March 25, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 30, 2021, through 
August 2, 2021 with the reported diagnosis G93.41, metabolic encephalopathy. 
 
You asked the Plan to pay for inpatient services provided from July 30, 2021, through August 2, 2021 with the 
reported diagnosis G93.41, metabolic encephalopathy. The Plan denied your request. The Plan says that the 
medical records do not support DRG 380, complicated peptic ulcer with MCC. 
 
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 G93.41, metabolic encephalopathy. 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 services provided from July 30, 2021, through 
August 2, 2021 with the reported diagnosis G93.41, metabolic encephalopathy. Our reviewer says that the 
documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that 
the enrollee is an 84 year old female with baseline dementia who was admitted and treated for a bleeding 
esophageal ulcer. Metabolic encephalopathy was listed as a secondary diagnosis. She was noted to be 
less talkative than usual and appeared tired but had no other neurological deficit or loss of consciousness. 
Symptoms improved to closer to baseline following fluids, blood transfusion. Based on the provided 
documentation there was insufficient support made for the diagnosis of metabolic encephalopathy. The 
symptoms of fatigue and weakness were directly related to her anemia and as she responded to treatment for 
this it would not be categorized as a metabolic encephalopathy.   
 
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 services provided from July 30, 2021, through August 2, 2021 with the reported diagnosis  
G93.41, metabolic encephalopathy.