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

 
We decided that the Plan has to pay for the inpatient hospital services provided from July 26, 2021, to August 
10, 2021, billed with diagnosis related group (DRG) code 659. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 659. You say that the 
documentation in the medical record clearly supports the clinical diagnosis of Metabolic encephalopathy. The 
Plan denied your request. The Plan says that DRG 659 is not supported as the diagnosis of Metabolic 
encephalopathy. 
 
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 secondary diagnosis code, G93.41, defined as 
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 the inpatient 
hospital services billed with DRG 659. Our reviewer says that the submitted DRG is supported. Our physician 
reviewer found based on the provided documentation, the enrollee was likely experiencing side effects from 
narcotics and anesthesia which would be considered a toxic delirium which is a form of metabolic 
encephalopathy, and improved with time and changes to the treatment plan. Our reviewer found that therefore, 
the documentation supports this diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided from July 26, 2021, to August 10, 2021, billed with diagnosis related group 
(DRG) code 659.   
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 pay for the hospital bed provided on April 6, 2022. 
 
You asked the Plan to pay for the bed. The Plan denied your request. The Plan says duplicate items are not 
covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had a dry pressure mattress at the time the hospital bed was received. The dry 
pressure mattress serves the same purpose as the hospital bed. Therefore, we decided that the Plan does not 
have to pay for the hospital bed provided on April 6, 2022.
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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy or can tolerate this therapy on an intensive IRF level. Therapy documents note therapy is 
limited by weakness and dizziness. 
 
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 pre-approve epidural steroid injections, lumbar and sacral, (64483, 
64484). 
 
You asked the Plan to pre-approve the injections. You say that the services should be approved. The Plan 
denied your request. The Plan says there was not at least 50% sustained improvement of pain relief and/or 
improvement of function for at least three months after the most recent injections. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee had a prior transforaminal epidural steroid injection performed on July 7, 2022. The 
documentation shows they did not experience at least 50% sustained improvement in pain relief and/or 
improvement in function for at least three months. Therefore, the requested injections are considered 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections, lumbar and sacral, (64483, 64484).
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 are appealing the denial of authorization for 
acute inpatient rehabilitation facility level of care. The Plan denied your request. The Plan says based upon 
your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily 
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 you have a history including atrial fibrillation, chronic lung disease, cardiac 
disease and previous stroke who was admitted to the hospital with a complaint of low back pain and weakness. 
You were diagnosed with acute on chronic low back pain and sciatica. You have been medically stable. The 
most recent therapy notes indicate that you require moderate assistance for bed mobility and transfers and are 
able to ambulate with assistance and a hemi-walker. 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: 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 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 documentation does not support the need for a therapy program consisting of at least 
3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. 
There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical 
therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 
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 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 pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary. Our physician reviewer found the 
enrollee had been approved for 3 units of code 96133. Utilizing the criteria from LCD L33632 that this testing 
is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly 
on or indirectly on the brain including detection of neurologic disease based on quantitative assessment of 
neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of 
neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or 
progression of central nervous system disorders or assessment of neurocognitive function for the formulation of 
rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, this enrollee 
does not meet the criteria for an additional 3 units of code 96133 as the enrollee is not showing severity of 
symptoms that would warrant the addition of 3 units of code 96133 as being reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (87811) provided on February 9, 2022, 
for travel purposes. 
 
You asked the Plan to pay for COVID-19 testing. You say that this should be a covered expense as it was 
required by the government for you to get back into the country. The Plan denied your request. The Plan says 
services are only covered when they are provided for medical purposes. COVID-19 testing received for the 
purpose of travel is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that services which are not medically necessary for 
the diagnosis or treatment of an illness or injury are not covered. The Plans rules say that COVID-19 testing 
conducted to test for general workplace safety or public health surveillance, or for any purpose not primarily 
intended for the individualized diagnosis or treatment of COVID-19 or another health condition is not a 
covered benefit. This includes screenings for travel or vacation.  
 We looked at the file and Medicare rules. The COVID-19 test in this case was provided out-of-country in order 
to regain access to the United States. Based on this information, we decided that Medicare rules for coverage of 
COVID-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 
testing (87811) provided on February 9, 2022, for travel purposes.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0429) and ground mileage 
(A0425) provided on March 30, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
live alone, had no other way to the hospital, and needed to be transported by ambulance. You also say that you 
have vertigo with prescribed medication, could hardly walk, were unbalanced, and it was dangerous for you not 
to be transported by ambulance. The Plan denied your request. The Plan says that the ambulance company has 
designated this trip as a non-billable service, and these services are unable to be covered by the Plan. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and 
ground mileage. Our reviewer says that these services were medically reasonable and necessary. Our physician 
reviewer found you had vertigo and live alone. You required ambulance transportation to the emergency 
department for evaluation. Our reviewer also found that your presenting symptoms meet prudent layperson 
criteria for emergency 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 the emergency ambulance transportation and ground mileage have been met. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on March 30, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that in the last year, you have noticed that 
your eyesight has worsened. You also say the network specialist has treated you, but you have seen no 
improvement. The Plan denied your request. The Plan says the requested provider is an out-of-network 
provider and the service requested may be provided by a participating provider with the Plan. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
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 the enrollee can be transferred to 
LTACH level of care for continuation of care for her complex medical needs that require on-going acute care. 
The Plan denied your request. The Plan says authorization denied because the LTACH is not medically 
necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 record indicates that the enrollee is improving but still require acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied.  
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service May 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says Eliquis is a self-administered drug which does not 
fall under Part B coverage. The Plan says that the enrollee does not have a pharmacy benefit administered 
under this contract. 
 
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 Eliquis 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for diagnostic radiology provided on 
December 3, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services for diagnostic radiology provided on 
December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on March 21, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record sent by the provider shows a definitive urine drug test panel for multiple drug 
classes was performed, but does not show presumptive screening test results which are inconsistent with 
prescription medications, dosing schedules, or history and expected results. Therefore, the requested definitive 
drug testing 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on March 21, 2022.