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

 
We decided that the Plan does not have to pay for inpatient hospital services provided from June 5, 2021, to 
June 12, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the diagnosis was clinically 
evaluated. The Plan denied your request. The Plan says the secondary diagnosis 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 provided with J96.01, defined as acute respiratory failure with 
hypoxia. 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. Our 
physician reviewer found that the enrollee was treated for pericarditis.  Documentation of chronic respiratory 
disease or home oxygen use was not noted in the record. Arterial blood gas values were not noted in the record. 
The records do not support the billed diagnosis code at issue.  
 
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 from June 5, 2021, to June 12, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
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 enrollee needs Acute Inpatient Rehab as there is 
no one there to assist them. The Plan denied your request. The Plan says the criteria for admission to the Acute 
Inpatient Rehabilitation setting have not been met. The enrollee's ongoing skilled therapy and nursing needs 
can be provided at 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 the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided to the enrollee on May 10, 
2022. 
 
You asked the Plan to pay for the services. You say that there were two different providers. The Plan denied 
your request. The Plan says this was not reported correctly. 
 
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 99232 
is a column II code to column I code 99223 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 subsequent hospital care provided to the enrollee on May 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from December 3, 
2021, to December 6, 2021. 
 
You asked the Plan to pay for the services provided. You say that the coding is correct per the coding 
department. The Plan denied your request. The Plan says the claim is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code J0604 has a status indicator of B. 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 outpatient hospital services provided from December 3, 2021, to December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (27279). 
 
You asked the Plan to pre-approve right sacroiliac fusion 27279. You say that you really need this surgery. You 
have had numerous injections, radiofrequency, physical therapy and medications and you have a spinal cord 
stimulator implanted. You are in so much pain and do not know what else to do. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for the requested right sacroiliac joint fusion. 
 
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 right sacroiliac fusion 27279. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures directed to the SI joint including 
bracing and physical therapy. Additionally, the imaging studies provided did not rule out other possible causes 
of pain in the lumbar spine and/or hips. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the medical records provided do not meet the medically necessary requirements listed in the LCD for Medicare 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right sacroiliac fusion 27279 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 21, 2021, billed 
with codes 81206, 81162, 81292, 81295, 81298, 81301, 81317, 81321, 81194 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
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 
November 21, 2021, billed with codes 81206, 81162, 81292, 81295, 81298, 81301, 81317, 81321, 81194 and 
81401.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested continued use of a non-
invasive home ventilator is medically necessary for treatment of chronic respiratory failure secondary to 
chronic obstructive pulmonary disease (COPD.) The Plan denied your request. The Plan says the enrollee's 
compliance report shows that they failed to use the home mechanical ventilator consistently. 
 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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found you have chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. The records show that you are using "Trilogy 
BiPAP." Additionally, provided records document that the home ventilator is being requested for use in 
average volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by 
a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. The provided records do 
not clearly support that you have been using the ventilator to meet Medicare criteria for continued coverage. A 
note dated June 6, 2022, states that you had been having severe reflux and therefore haven't been wearing 
Trilogy like you should. On September 9, 2022, another note reports that you hadn't been able to use Trilogy 
due to stomach pain and bloating. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
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 services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
unilateral primary osteoarthritis of the right knee. Detailed documentation is not evident regarding 
osteoarthritis affecting just one compartment of the right knee. The x-rays dated June 16, 2022 showed 
moderate tricompartmental arthritis of the right knee; moderate joint space narrowing and subchondral 
sclerosis, as well as periarticular osteophytes of the right knee. There are limited large-scale, long-term 
references showing the safety and efficacy of partial knee arthroplasty 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 to guidelines. Therefore, the requested right knee partial arthroplasty, in this case, 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs additional days for their medical 
condition. The Plan denied your request. The Plan says the Medicare guidelines for LTACH admission were 
not met and the enrollee is receiving the care they need in the current hospital they are at. 
 
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 enrollee appears to be unstable requires short-term additional acute care 
services that can safely be performed at the current facility until more stable for transfer. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tymlos injection. 
 
You asked the Plan to pre-approve a Tymlos injection. The Plan denied your request. The Plan says Tymlos 
Injection is on the self-administered drug list and is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Tymlos injection.  
 
Benefits for a Tymlos injection 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable to be 
transferred to LTACH level of care. The Plan denied your request. The Plan says LTACH is not medically 
necessary because the level of care provided in LTACH setting is more than the enrollee's medical condition 
needs. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care 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 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 durable medical equipment/supplies under the special 
supplemental benefit for the chronically ill (SSBCI) coverage. 
 
You asked the Plan to pre-approve durable medical equipment/supplies under the SSBCI coverage. You say 
that the requested services are medically necessary. The Plan denied your request. The Plan says the enrollee 
does not have a need for intensive care management and is not high risk for hospitalization with the diagnosis 
of neurological disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. The medical records do not document that you are at high risk for 
hospitalization or that you require intensive care coordination. A letter of medical necessity from your provider 
reports a neurological condition but the provided records do not support the diagnosis of a serious neurologic 
disease such as amyotrophic lateral sclerosis (ALS), epilepsy, extensive paralysis (i.e., hemiplegia, 
quadriplegia, paraplegia, monoplegia), Huntington's disease, multiple sclerosis, Parkinson's disease, 
polyneuropathy, spinal stenosis, or stroke-related neurologic deficit or stroke. Based on this information, we 
decided that Medicare rules for coverage of durable medical equipment/supplies under the SSBCI coverage have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in 
the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve durable medical 
equipment/supplies under the special supplemental benefit for the chronically ill (SSBCI) coverage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20610) provided on March 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20610. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20610) 
provided on March 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a right shoulder magnetic resonance imaging (MRI) (73221). 
 
You asked the Plan to pre-approve an MRI of the right shoulder. You say that the enrollee will need a right 
shoulder MRI to evaluate for progression of rotator cuff tear. The Plan denied your request. The Plan says that 
the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the right shoulder. Our 
reviewer says that an MRI of the right shoulder Our physician reviewer found the x-rays showed high riding 
humeral head which is indicative of a chronic rotator cuff tear. Provider notes 6 weeks of physical therapy. Our 
reviewer also found that the enrollee qualifies for an MRI of the right shoulder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the right shoulder have been met. Therefore, we decided that the 
Plan has to pre-approve a right shoulder magnetic resonance imaging (MRI) (73221).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 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 that you appear to still be unstable and require additional acute care services that can 
safely be performed at the current facility until you are more stable for transfer. You do not require services at 
the LTACH that are not already available at the current facility. 
 
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 LTACH services.