Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a reported diagnosis of osteoarthritis of the knee. The record does not indicate the failure of a trial 
of nonpharmacological therapy and does not include radiographic documentation to support the stated 
diagnosis. The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's 
condition. However, the record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Orthovisc (J7324).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia (00812) and a diagnostic colonoscopy 
(45378). 
 
You asked the Plan to pre-approve anesthesia and a diagnostic colonoscopy. You say that your last 
colonoscopy was in 2015. The Plan denied your request. The Plan says you do not have a risk factor that 
requires a screening colonoscopy more frequently than every 10 years. 
 
The Plan follows Medicare rules. Medicare rules say that the A/B Medicare Administrative Contractor (MAC) 
(B) must pay for screening colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy 
at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer. 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 anesthesia and a diagnostic 
colonoscopy. Our reviewer says that you do not meet the criteria for coverage for anesthesia and a diagnostic 
colonoscopy at this time. Our physician reviewer found there is no documentation that supports that you are at 
a high risk for developing colorectal cancer to meet Medicare criteria for the anesthesia (00812) and diagnostic 
colonoscopy (45378). Provided records do not document any personal medical history, family medical history, 
symptoms or physical examination findings or laboratory testing results which would support that you are at a 
high risk for developing colorectal cancer. Our reviewer also found that based on the provided records, you 
would appear to be due for a screening colonoscopy in 2025. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia and a diagnostic colonoscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve anesthesia (00812) and a diagnostic colonoscopy (45378).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that the enrollee was 
transported twice on the same date of service. The Plan denied your request. The Plan says this claim does not 
meet the requirements for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 non-emergency ambulance 
transportation. Our reviewer says that transportation by ambulance from a radiology appointment to the 
enrollees residence was not medically necessary. Our physician reviewer found the enrollee was not 
bedridden, as evidenced by their ability to sit in a recliner. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Our reviewer 
found that transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees condition. Our physician reviewer also found that a prudent layperson 
would not believe that immediate medical attention was required for someone attending a scheduled 
appointment. 
 
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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided 
on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump, 
stationary or portable (E2402). 
 
You asked the Plan to pre-approve a negative pressure wound therapy electrical pump. You say that you have 
submitted medical records to support the request for reconsideration of the authorization denial. The Plan 
denied your request. The Plan says the requested services are not reasonable and necessary, and the health plan 
has no contractual obligation to cover services that are not covered by Medicare. 
 
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 negative pressure wound therapy 
electrical pump. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of abdominal wound. The 
enrollee underwent surgery for recurrent adenocarcinoma of the colorectal anastomosis with an abdominal 
wound dehiscence. The enrollee had a procedure with a wound vacuum placed June 21, 2022. and approved 
through October 21, 2022. The enrollee had the device greater than 4 months. According to Medicare criteria, 
coverage for a NPWT pump is considered reasonable and necessary for four (4) months (including the time 
NPWT was applied in an inpatient setting prior to discharge to the home). The review has determined that the 
requested wound vacuum is not medically necessary for the enrollee. The enrollee does not meet LCD criteria 
for approval. 
 
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 negative pressure wound therapy electrical pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical 
pump, stationary or portable (E2402).
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 
January 26, 2022, to February 1, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis is supported by physician documentation, prophylactic treatment including pneumatic compression boots, Lovenox administration and official coding guidelines. The Plan denied your request. The Plan says the 
DRG was updated. 
 
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 190. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the patient has chronic thrombocytopenia. Platelet counts fluctuated from 101 to 144 K/cmm. 
An international normalized ratio and partial thromboplastin time were not found in the medical record. In 
addition, there was no evidence of bleeding. The review has determined that the documentation did not support 
the use of diagnosis code D68.69 - other thrombophilia. The records did not support the use of DRG 190 in this 
case.  
 
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 January 26, 2022, to February 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to 
May 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to May 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 30, 2022.
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 
August 25, 2021, to August 28, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service postpay 
clinical validation audit shows that 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 871. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the physician documented a diagnosis of acute on chronic renal failure and no baseline 
creatinine was provided. While the initial creatinine was 1.5, this improved to 1.2 following intravenous fluids. 
The creatinine on the day of discharge was 1.0. In this case, the creatinine was not 1.5 times or more from the 
imputed baseline following adequate fluid resuscitation. The review has determined that the documentation did 
not support diagnosis code N17.0 - acute kidney failure with tubular necrosis. The records did not support DRG 
871 in this case.  
 
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 August 25, 2021, to August 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 01402) provided to the 
enrollee on March 15, 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 the records do not support the services billed. 
 
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 01402 is "Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty." 
 
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 that the medical records submitted 
include an anesthesia plan/pre-operative note and post-operative note. However, the intra-operative 
anesthesiology record was not available in the records submitted. There was no documentation of the 
intraoperative anesthesia care/ intraoperative monitoring, or the surgical procedure note from the surgeon performing the surgical procedure. CPT 01402 cannot be verified as rendered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 01402) provided to the enrollee on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 5, 2022.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says based on Medicare 
guidelines, the LTACH services requested do not meet the requirements for approval. 
 
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 there is no evidence that you require services that are not available at the acute care 
hospital where you are currently receiving care. You can remain at the current acute care hospital until such 
time no acute services are required. You can then be transferred/discharged to a lower level of care for any 
ongoing long term care needs. 
 
 
 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 incontinence supplies (T4528). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are a medical 
necessity for you. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4528).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
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 requested Minuteman procedure is 
considered experimental in nature. More research is needed to support its use. 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 a Minuteman procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift (S5165). 
 
You asked the Plan to pre-approve a stair lift. You say that you have two artificial knees, your bedroom is on 
the second floor, but you currently sleep on the first floor living room. You are requesting approval so you can 
sleep in your bedroom again. The Plan denied your request. The Plan says there is a full bathroom and kitchen 
on the first floor. You can complete your activities of daily living on the first floor of your home. Therefore, 
given the provided documentation, you do not meet the guidelines for the requested service which does not 
appear medically necessary. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (S5165).
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 need to go to rehab to regain your prior baseline 
of function to return home to your family. The Plan denied your request. The Plan says this 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 your 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88344 billed for date of service 
May 31, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88344. You say that the reports support medical 
necessity. The Plan denied your request. The Plan says payment for codes 88341 and 88344 are bundled into 
payment for code 88360. 
 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 codes 88341 and 88344 are column II codes to column I code 88360. The 
codes have 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 codes 88341 and 88344 billed for date of service May 31, 2022.