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. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary and 
the patient's needs will not be able to be met at a lower level of care. The Plan denied your request. The Plan 
says the patient's current needs can be met at the current acute care facility. When the patient is ready to leave 
the hospital, they can receive appropriate care in a lower-level 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. Our 
physician reviewer found the patient is a 53 year-old female who was admitted to the acute care hospital with 
occlusion of left limb artery requiring heparin drip, aortogram, thrombectomy, angioplasty, pain medication, 
complicated by hematoma and compartment syndrome requiring fasciotomy and blood transfusion for anemia. 
The patient has been receiving debridement, wound care, diuresis, additional blood transfusion, wound VAC. 
Recent notes describe the patient with stable hemoglobin, however, with partially open incision requiring 
incision and packing. The patient appears to be more stable and improving and should only require short-term additional acute care services that can be safely administered at the current facility until more appropriate for a 
lower level of care. The patient does not appear to be tolerating weaning. The patient does not require services 
at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is needed so that you can return 
home from the hospital. The Plan denied your request. The Plan says that your needs can be met with a 
different device. 
 
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. Specifically, the Plan has failed to supply any medical records at all in the case 
file it submitted to us.  Without medical records, we cannot determine if the device alternative that the Plan is 
offering will meet your needs or not.  The burden is on the Plan to show that its denial is correct.  By failing to 
provide any medical records, the Plan has not met this burden. Therefore, we decided that the Plan has to pre-
approve a home ventilator.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (82465) provided on December 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 82465 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 services (82465) provided on December 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rhinoplasty. 
 
You asked the Plan to pre-approve rhinoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 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 rhinoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the requested rhinoplasty is medically reasonable and 
necessary for the enrollee in this case. No functional problem with the enrollee's nose is identified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rhinoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rhinoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83789) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested specimen validity testing is not separately payable. 
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 the lab services (83789) provided on December 
15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like to request 
reconsideration because your daughter goes to this facility and would be able to take you whenever she goes. 
You say that you feel more safe and secure riding with her. The Plan denied your request. The Plan says you 
must receive your care from a network provider. There are in-network providers located within a 1-mile radius 
of your residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy visits to be provided by OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee meets LTAC admission criteria 
under CMS guidelines. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator with 
settings that could be delivered by BiPAP with AVAPS for this enrollee with COPD is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does have chronic 
obstructive pulmonary disease, but chronic respiratory failure is not clearly supported in the provided records. 
Records do not document neuromuscular disease. Her pulmonary function study of 06/28/2022 shows a mixed 
restrictive/obstructive pattern. As stated in the Local Coverage Determination (L33800), claims for ventilators 
used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 
not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81324 and 81405. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 8, 2022, billed with codes 81324 and 81405.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 7, 2021, through 
August 10, 2021, at DRG 872. 
 
You asked the Plan to pay for inpatient services at DRG 872. You say that sepsis due to E. coli is supported 
based on provider documentation, treatment, monitoring, clinical evaluation, coding advisement and official 
guidelines. You say that the coding should not be changed. The Plan denied your request. The Plan says 
principal diagnosis code A41.51 is not supported. 
 
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 with principal diagnosis code A41.51, defined as sepsis due to 
Escherichia coli [E. coli]. 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 
at DRG 872. Our reviewer says that the documentation does not support principal diagnosis code A41.51. Our 
physician reviewer found that there was no clinical or laboratory evidence of sepsis. Though a diagnosis of 
sepsis was noted during the stay, there was no evidence of significant thrombocytopenia, hepatic dysfunction, 
hypoxia, acute mental status changes or persistent hypotension.  
 
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 August 7, 2021, through August 10, 2021, at DRG 872.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Zilretta injection. 
 
You asked the Plan to pre-approve a repeat Zilretta injection. You say that you were told you could get another 
injection. The Plan denied your request. The Plan says only one injection is supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 repeat Zilretta injection. Our reviewer 
says that the requested use of Zilretta is not supported. Our physician reviewer found the safety and 
effectiveness of repeat administration of Zilretta have not been proven. 
 
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 repeat Zilretta injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat Zilretta injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone scan to be provided by an out-of-network (OON) 
hospital. 
 
You asked the Plan to pre-approve the OON bone scan. You say that you had this same test in February at this 
facility, so you would like to go there again. The Plan denied your request. The Plan says there are plan 
facilities that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a bone scan to be provided by an out-of-network (OON) hospital.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
sepsis and urinary tract infection. 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 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. 
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 inpatient rehabilitation facility (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 you would like to be admitted to inpatient 
rehabilitation so you can return to your prior level of function. The Plan denied your request. The Plan says 
rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vitamin assays (82306, 82728, 83540, 84466 and 86141) 
performed as part of a general health panel provided on June 15, 2021. 
 
You asked the Plan to pay for vitamin assays. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says these services are not covered 
for screening purposes. 
 
The Plan must follow Medicare rules. The rules say that Medicare considers vitamin assay panels (more than 1 
vitamin assay) a screening procedure and therefore, non-covered. 
 You have requested payment for multiple vitamin assays which were billed with multiple procedure codes. The 
medical records provided indicate that these tests were performed as part of a requested Complete Wellness 
Panel. Medicare does not cover or pay for these services as they are considered a screening procedure and 
therefore are non-covered. Therefore, we decided that the Plan does not have to pay for vitamin assays (82306, 
82728, 83540, 84466 and 86141) performed as part of a general health panel provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01926 billed on November 22, 2021. 
 
You asked the Plan to pay for procedure code 01926. You say that the QX modifier was appended indicating a 
nurse anesthetist service with medical direction by an anesthesiologist. You say that the claim should be 
reviewed and reprocessed for necessary payment. The Plan denied your request. The Plan says there are no 
modifiers allowed with this code pair. 
  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 01926 
is a column II code to column I code 61624 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 01926 billed on November 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on February 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapy visit. You say that you disagree with the denial of therapy services. The 
Plan denied your request. The Plan says that there was no authorization approved before the enrollee received 
this service. 
 
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 physical therapy visit provided on February 3, 
2022, by an out-of-network (OON) provider.