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 services are medically necessary as the enrollee 
has already failed at lower levels of care. The Plan denied your request. The Plan says the services the enrollee 
needs can be provided safely in another setting such as a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this to regain prior level of 
function, and this can't be provided at sub-acute level. The Plan denied your request. The Plan says the 
enrollee's records do not show the need for an intensive team for care, services needed can be provided safely 
in other settings a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you need a home ventilator to sustain life 
and not return to the intensive care unit. The Plan denied your request. The Plan says your needs can be met 
with bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
capabilities. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found you were hospitalized last 
month for a flare of chronic obstructive pulmonary disease (COPD), and your provider said that your 
compliance was questionable regarding the use of your home BiPAP. During that hospital admission you were 
treated with BiPAP with improvement. The submitted information does not provide any documentation that 
you have failed with a BiPAP or a continuous positive airway pressure (CPAP) device. Instead, the records 
document that you improved with BiPAP. The hospital notes say that you have a BiPAP at home and in the 
hospital your provider talked to you about the importance of using it as prescribed. You were advised to be 
more compliant with BiPAP. Additionally, this ventilator is being requested in an average volume assured 
pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with 
AVAPS and a back-up rate. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 94100 billed for date of service 
July 20, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 94100. You say that the codes are payable. The Plan 
denied your request. The Plan says procedure codes 99100 and 94100 are considered bundled and not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that procedure codes 99100 and 94100 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 94100 is not separately payable. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99100 and 94100 billed for date of service July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 4, 2022, 
through July 5, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented with fluid overload, decreased breath sounds, bilateral edema, 
Hyponatremia, normal creatinine, and was treated with diuretics. Other workup and objective findings were 
unremarkable, and the enrollee was stable and only needed short-term supervised diuresis. It was not expected 
that she would require hospital services that would likely cross two midnights. 
 
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 pay for the acute inpatient hospital care provided from July 4, 2022, through July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for 
treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, 
sensing lead, implantable pulse generator) (0424T). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the request for an implantable phrenic nerve stimulator for the treatment of 
complex/central sleep apnea is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found there is no evidence that a recent PAP titration study was performed. It does not appear that other 
positive airway pressure (PAP) devices including adaptive servo-ventilation (ASV) have been attempted due to 
similar interface issues. There is no description of alternate interface use including nasal pillows, nasal cannula, 
or primary oral mask use. There is no evidence that provider has attempted a PAP titration study to determine 
ideal pressures or considered a trial of bilevel positive airway pressure (BiPAP) to permit reduced expiratory 
pressures. There is no evidence that provider has utilized an adaptive support ventilation (ASV) device to assist 
in the treatment of central apneas. There is no evidence that member has utilized a variety of interface devices 
that may improve mask positioning. The review has determined that the medical records provided does not 
meet the requirements listed in the NCD 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion or replacement of neurostimulator system for treatment of central sleep apnea; 
complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse 
generator) (0424T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81479) provided on September 30, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and 
reasonable. The Plan denied your request. The Plan says there is insufficient medical documentation to support 
the necessity of these services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory testing have been met. 
Specifically, there are no physician notes or medical records from the ordering provider to support that they are 
treating the enrollee and to show why these services are necessary. Therefore, we decided that the Plan does 
not have to pay for laboratory testing (81479) provided on September 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 30, 2022, to 
April 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as sepsis, 
unspecified organism. 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 at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found there was insufficient evidence documented to support the patient was 
experiencing a dysregulated response to systemic infection leading to organ failure to meet Sepsis 3 criteria.  
 
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 on March 30, 2022, to April 1, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty and panniculectomy. 
 
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 that the records show you have a hernia 
that is getting bigger with worsening symptoms over the previous year. A physical examination documented 
the hernia was tender and the skin was intact without rash. The records do not contain documentation of 
significant complications related to the excess abdominal skin (panniculus). The services are therefore not 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an abdominoplasty and panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nasal/sinus endoscopy, surgical, with sphenoidotomy 
(31287). 
 
You asked the Plan to pre-approve a surgical service. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested service 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 pre-approve a surgical service. Our reviewer says 
that the requested surgical service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records do not document involvement of the sphenoid sinus to meet 
criteria for the requested nasal/sinus endoscopy, surgical, with sphenoidotomy. Therefore, the reviewer found 
that the requested surgical service 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 a surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nasal/sinus endoscopy, surgical, with sphenoidotomy (31287).
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 it is medically necessary. The Plan denied your 
request. The Plan says it 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pulmonary edema, atrial fibrillation, and progression of kidney disease. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse shoulder arthroplasty. 
 
You asked the Plan to pre-approve the requested shoulder surgery. You say that the enrollee would benefit 
from this procedure. The Plan denied your request. The Plan says records do not show evidence of massive 
rotator cuff tear, failed prior surgery, humeral fracture, or posterior glenohumeral subluxation. 
 
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 the requested shoulder surgery. Our 
reviewer says that the requested shoulder surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding diagnostic imaging 
corroborating a large and massive rotator cuff tear that is irreparable. There is no indication of any previously 
failed surgeries in the left shoulder. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
reverse shoulder 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 the requested shoulder surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a reverse shoulder arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that in light of the patient's specific clinical need, 
the CardioMEMS implant is medically necessary. The Plan denied your request. The Plan says the 
CardioMEMS device is investigational and is therefore only coverable in the context of a clinical trial or study. 
The patient does not meet criteria for inclusion in the approved trial/study, so this procedure cannot be 
approved. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with congestive heart failure. The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
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 would benefit from inpatient 
rehabilitation level of care. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements, services may be safely provided in an alternate setting, a skilled nursing facility, outpatient 
setting or home health 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 enrollee is functioning at or near a home care level and does not require intensive 
or complex rehabilitation and does not require frequent physiatry oversight. 
 
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.