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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee recently underwent a major surgery and 
requires acute care. You also say that the services provided at a skilled nursing facility are not sufficient for the 
enrollee's recovery. The Plan denied your request. The Plan says the Medicare criteria for admission to an IRF 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our 
physician reviewer also found that 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27446). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service 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 a total knee arthroplasty. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The documentation does not corroborate a trial and 
failure of physical therapy or hyaluronic injections for the left knee. A magnetic resonance imaging (MRI) scan 
of the left knee had impressions of medial meniscal tear and only early degenerative change. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception.  
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27446).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or use an insulin pump. 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 pre-approve 
a continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories (K0858, 
E2363, E1028, E1002, E2311, E1012, E0955, E2623). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that this wheelchair 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with accessories (K0858, E2363, E1028, E1002, E2311, E1012, E0955, E2623).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting an appeal regarding the denial of coverage for the Flexitouch pneumatic compression pump 
prescribed to treat lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oseltamivir capsule and Levofloxacin tablets provided in an 
outpatient setting from December 8, 2021, to December 9, 2021. 
 You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital with the flu, 
covid, and pneumonia. You also say that you should not have to pay for this. The Plan denied your request. The 
Plan says the self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the self-administered drugs are not covered under Medicare 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 pay for Oseltamivir capsule and 
Levofloxacin tablets provided in an outpatient setting from December 8, 2021, to December 9, 2021.  
 
Benefits for the self-administered drugs 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 drug testing services provided to the enrollee on December 
27, 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 the records do not demonstrate your specific history, physical exam findings, current treatment plan, risk assessment plan and how the test results are needed for the doctor to make clinical decisions about 
care. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare guidelines require the reason for the testing to be documented. The clinician's rationale for the 
definitive testing and the tests ordered must be documented in the patient's medical record. In this case, the 
records do not demonstrate the enrollee's specific history, physical exam findings, current treatment plan, risk 
assessment plan and how the test results are needed for your doctor to make clinical decisions about his care. 
The review has determined that the enrollee does not meet the criteria for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on December 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 17, 2021, to January 2, 2022. 
 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 skilled services were not required. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided, there 
is no documentation that the patient required skilled nursing or skilled therapy services, i.e., the specialized 
skill, knowledge and judgment of a skilled professional nurse or qualified therapist were not required to safely 
and effectively provide medically necessary and reasonable treatment from 12/17/2021 through 
01/02/2022. The records did not document the need for intravenous medications, new tube feeding or ostomy 
care or daily complex wound care during the time period in question. Daily skilled services were not required, 
as the enrollee was receiving custodial care. This patient did not require the services on an inpatient basis, only 
in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 17, 2021, to 
January 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up ventilator battery. 
 
You asked the Plan to pre-approve the back-up ventilator battery. You say that you would like reconsideration 
because the battery you have only holds charge for 4 hours and 30 minutes, which is not long enough when you 
are out of your home. The Plan denied your request. The Plan says duplicate or redundant durable medical 
equipment such as a back-up battery is 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 you have a ventilator battery. The ventilator battery that you have serves the same purpose 
as the back-up battery that you are requesting. Additionally, the file indicates that you are requesting this 
equipment for use outside of your home.  
  
Therefore, we decided that the Plan does not have to pre-approve a back-up ventilator battery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided on November 30, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that this genetic testing met all national and 
local coverage rules and should be covered. The Plan denied your request. The Plan says you did not have prior 
authorization for this genetic testing. 
 
Medicare rules say that plans can require prior authorization for services. The contract with the Plan says that 
the Plan requires prior authorization for all genetic testing not related to pregnancy.  You did not request prior 
authorization for the genetic testing at issue in this appeal. Therefore, we decided that the Plan does not have to 
pay for genetic testing services provided on November 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee's knee continues to feel stiff, 
and her legs feel heavy. She is making progress but would benefit from continued therapy instruction. The Plan 
denied your request. The Plan says the requested therapy is not medically necessary in this case. The enrollee 
would be receiving repetitive therapy, has achieved functional recovery and is able to do a home exercise 
program. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional physical therapy (PT) visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional evaluation and management services provided to 
the enrollee on January 17, 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 this denied correctly for exceeding the maximum number of units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We asked our 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 a review of the claims history shows 
that the exact same service (99285) was already billed for this patient, and for same date of service under claim 
820220321612719 by same provider. The reviewed records did not support that the second visit was for an 
unrelated problem to the first visit. 
 
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 additional evaluation and management services provided to the enrollee on January 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on December 1, 2021, billed 
with code 15004. 
 
You asked the Plan to pay for the surgical services as billed. You say that this was billed correctly and should 
be paid. The Plan denied your request. The Plan says the billed code 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 15004 is Surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children. 
 
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 surgical services as billed. Our reviewer says that the billed code at issue is not supported by the records. Our reviewer found the procedure report describes wound 
debridement for skin graft.  In, this case this procedure would be inclusive to the graft procedure. Debridement 
of a skin wound (e.g., CPT codes 11000, 11042-11047, 97597, 97598) prior to a graft/skin substitute is 
included in the skin graft/skin substitute procedure (CPTcodes 15050-15278) and shall not be reported 
separately. If the recipient site requires excision of open wounds, burn eschar, or scar or incisional release of 
scar contracture, CPT codes 15002- 15005 may be separately reportable for certain types of skin grafts/skin 
substitute. This is not documented in this case. 
 
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 surgical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on December 1, 2021, billed with code 15004.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
19, 2020, to June 27, 2020. 
 
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 the provider has reported inpatient hospital services with the incorrect DRG.  
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 DRG 844 (OTHER MYELOPROLIFERATIVE 
DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC). 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found the admission history and 
physical examination report described the patient as having appeared well-developed and well-nourished. 
There was no documentation of weight loss. The patient was provided with a regular hospital diet, without 
provision of oral nutritional supplements. There was no consultation or evaluation by the Hospital 
Dietician/Nutritionist. The appropriate DRG is DRG 845: OTHER MYELOPROLIFERATIVE DISORDERS 
OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 19, 2020, to June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve RFAs. You say that you need this procedure done every 3 months. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because you had recent 
radiofrequency ablations (RFAs) on February 4, 2022, March 4, 2022, and May 20, 2022 which exceeds 
Medicare's frequency limit. 
 
The Plan follows Medicare rules. Medicare rules state that repeat thermal facet joint radiofrequency ablation 
may be covered under certain circumstances. For each covered spinal region no more than 2 radiofrequency 
sessions will be covered per rolling 12 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 RFAs. Our reviewer says that you do 
not meet the Medicare criteria for the requested radiofrequency ablations (RFAs). Our physician reviewer 
found you have had a series of RFA treatment every 3 to 4 months for facet related pain. Medicare covers no 
more than 2 radiofrequency sessions per spinal region per rolling 12 months. Your request exceeds the criteria 
and there are other alternatives available to you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations (RFAs).