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

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 3, 2020, through August 8, 2020, and billed with a principal diagnosis code of N17.9.
You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient hospital care as billed is supported in the medical records. The Plan denied your request. The Plan says the inpatient hospital care does not support a billed principal diagnosis of acute kidney failure.
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 principal diagnosis code, N17.9, defined as acute kidney failure, unspecified. 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 care as billed. Our reviewer says that the inpatient hospital care as billed is not supported in the medical records. Our physician reviewer found that the enrollee presented with weakness and mental status changes. The evaluation revealed a urinary tract infection (UTI). Her creatinine on admission was 2.2 but her baseline was 1.3 with a diagnosis of chronic kidney disease. She was admitted with a UTI and was started on IV antibiotics and IV fluids. Her creatinine decreased to 1.10 at discharge. There was no diagnosis of acute kidney injury. The review has determined that the medical records did not support the billed diagnosis code N17.9. 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 the inpatient hospital care provided from August 3, 2020, through August 8, 2020, and billed with a principal diagnosis code of N17.9.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (26145) provided to the enrollee on January 
13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 26145 remains not supported, as there is a more 
appropriate code to use. 
 
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 26145 is "Synovectomy, tendon sheath, radical 
(tenosynovectomy), flexor tendon, palm and/or finger, each tendon." 
 
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 the operative report documents open 
carpal tunnel release and ring finger A1 pulley release.  
 
CPT 26145 is an incorrect code to report for these procedures. The operative report does not include 
documentation of synovectomy tendon sheath. The procedures were reported incorrectly. 
 
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 surgical services (26145) provided to the enrollee on January 13, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says the required care is routine and does not require a team of providers.
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 does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for non-traumatic intraventricular cerebral bleed. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee. 
 
You asked the Plan to pre-approve Procrit. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no indication Retacrit would likely be less effective, and/or 
cause adverse effects for the member. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically reasonable and necessary for the enrollee. The provided records do not show that the patient 
has tried and failed Retacrit for his condition. Based on the provided documentation, there is no indication 
Retacrit would likely be less effective and/or cause adverse effects for the patient as all available erythropoietin 
stimulating agents have similar safety and effectiveness according to current evidence. Our physician reviewer 
found that the enrollee's condition does not meet step therapy criteria for Procrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have no family in the area to provide assistance 
and require a rehabilitation stay for care until you are cleared to fly home to North Carolina. You state if you 
are not discharged to rehabilitation, your functionality could be compromised post-operatively, including but 
not limited to inadequate healing of your complex incision. The Plan denied your request. The Plan says the 
stay 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from March 7, 2020, through 
March 11, 2020, with the reported principal diagnosis A40.0, Sepsis due to streptococcus, Group A. 
 
You asked the Plan to pay for inpatient services provided from March 7, 2020, through March 11, 2020, with 
the reported principal diagnosis A40.0, Sepsis due to streptococcus, Group A. The Plan denied your request. 
The Plan says according to coding guidelines and the documentation in the medical record, this condition did 
not qualify for reporting as the principal 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 the principal diagnosis of A40.0, Sepsis due to 
streptococcus, Group A. 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 
with the reported principal diagnosis A40.0, Sepsis due to streptococcus, Group A. Our reviewer says that the 
documentation does not support that the inpatient care is payable as billed. Our physician reviewer found the 
documentation supported an admission for Cellulitis of right lower limb. The documentation was 
inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis is documented on H&P, progress notes 
and discharge summary, supporting medical record documentation was not found within the record. The record 
did not show significant or persistent hemodynamic instability, cognitive impairment or end-organ dysfunction 
that would be consistent with multi-system involvement due to sepsis. Laboratory values of platelets, total 
bilirubin and creatinine were within normal limits. While the enrollee's presentation warranted consideration of 
sepsis as a diagnosis, there was no evidence of sepsis. The review has determined that the principal diagnosis 
A40.0, Sepsis due to streptococcus, Group A, was not supported by the medical records. 
 
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 March 7, 2020, through March 11, 2020, with the reported principal 
diagnosis A40.0, Sepsis due to streptococcus, Group A
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olmesartan Medoxomil for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Olmesartan Medoxomil for 
the enrollee.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy, or home with outpatient therapy. 
 
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 complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for lower extremity wounds and was discharged home with home health care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (77067-26, 77063-26, 76641-26-LT, 
76641-26-RT) provided on June 10, 2021. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the services 
billed. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that for 
Medicare to consider coverage and payment for any item or service, the information submitted by the supplier 
or provider must confirm that Medicare coverage criteria have been met. 
  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate groups of radiology services were provided on June 10, 2021. The file shows that the Plan paid for 
one group of codes 77067-26, 77063-26, 76641-26-LT, 76641-26-RT provided on June 10, 2021. Therefore, 
we decided that the Plan does not have to pay for the radiology services (77067-26, 77063-26, 76641-26-LT, 
76641-26-RT) provided on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 8, 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 G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of testing for the date of service at issue. 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 
drug testing rendered on March 8, 2021.
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 stay is medically necessary due to you living alone at home. You state inpatient rehabilitation is the only chance you have to regain your quality of life. The Plan denied your request. The Plan says the stay is not medically necessary based on the IRF criteria. The Plan states you can safely receive the services you need in other settings for example: a skilled nursing facility or home with home health services or home with outpatient therapy.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary, and the enrollee cannot get the care they need in another setting. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary skilled nursing and therapy services can be safely received in a lower level of care.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block (64454) provided on December 22, 2020.
You asked the Plan to pay for the genicular nerve block. You say that this procedure was medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational and not eligible for payment.
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 pay for the genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The requested procedure was therefore experimental/investigational for the enrollee's knee pain. 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block (64454) provided on December 22, 2020.