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

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the 
enrollee on September 12, 2022. 
 
You asked the Plan to pay for the services. You say that the documentation supports this code. The Plan denied 
your request. The Plan says this was denied because the enrollee's claim history indicates that the enrollee was 
discharged to home from the emergency room. 
 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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 record describes an 
emergency department visit on September 12, 2022, arrival 13:11 and departure 15:10. The documentation 
does not include a critical care note with time or services provided during critical care. Therefore, this 
procedure cannot be verified. 
 
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 critical care services (procedure code 99291) provided to the enrollee on September 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no skilled nursing needs. As of the last coverage day, you did not 
require any skilled nursing or skilled rehab services on a daily basis. You were not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. You do did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient 
basis, at a skilled level of care as of 2/15/23. As of 2/15/23, you only required custodial services. There is no 
need for further inpatient skilled care beyond the last covered day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the travel and lodging costs associated 
with an organ transplant incurred from April 10, 2022, through August 4, 2022. 
 
You asked the Plan to provide reimbursement for the travel and lodging costs. You say that you feel that you 
should still be entitled to this coverage because you did have to travel for this transplant. The Plan denied your 
request. The Plan says this transplant was received within the service area. As such, no coverage for travel and 
lodging is available. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans must provide reasonable travel and 
lodging for transplants only when the network transplant facility is outside the service area and outside of the community patterns of care for original Medicare beneficiaries who reside in the service area.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the travel and lodging costs have not been met. Specifically, there is no evidence that the transplant 
center used is outside of the community patterns of care in this area. Therefore, we decided that the Plan does 
not have to provide reimbursement for the travel and lodging costs associated with an organ transplant incurred 
from April 10, 2022, through August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 27, 2021, to 
October 29, 2021, 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 this 
claim was billed correctly and should be paid as billed. The Plan denied your request. The Plan says as the 
secondary diagnosis code was not supported, the DRG payment was correctly reduced. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code 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 at the DRG originally billed. Our reviewer says that the documentation does not support the 
use of diagnosis code J96.01. Our physician reviewer found there was no noted documentation of respiratory 
rates greater than 30, use of accessory muscles, or documentation of persistent decline in oxygen saturation. It 
is noted that the enrollee became short of breath while walking in the emergency room, and her saturation 
dropped to 89%. However, this resolved and there was no noted persistent (more than 2 sequential) decline in 
oxygen saturation. The review has determined that the documentation did not support secondary diagnosis code 
J96.01, defined as acute respiratory failure with hypoxia.  
 
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 October 27, 2021, to October 29, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer 750MG/15ML solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says they do not have a record from your prescriber that shows you have 
tried one of the preferred drugs (Ferrlecit, Infed or Venofer) and it has not worked, or that you have medical 
reasons that prevent you from using one of them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the Plan requires a trial of drug Ferrlecit, Infed or Venofer, before they will approve the requested drug. 
In this case, you have not tried and failed the required drug(s). There is no documentation provided indicating 
that the required drug(s) would likely be less effective and/or likely have adverse effects for 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer 750MG/15ML solution.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124), therapeutic exercises (97110), 
manual therapy (97140), and extraspinal chiropractic manipulative treatment (98943). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pre-approve massage therapy (97124), therapeutic exercises (97110), manual 
therapy (97140), and extraspinal chiropractic manipulative treatment (98943).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5110, D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service Jan 3, 2020. Therefore, 
we decided that the Plan does not have to pre-approve dentures (D5110, D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36620 and 76937 provided to the enrollee 
on October 15, 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 these services are not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 36620: 
 
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); 
percutaneous 
 
CPT 76937: 
 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
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 provided do 
not include sufficient documentation to validate that an arterial catheterization or cannulation for sampling, 
monitoring or transfusion (separate procedure); percutaneous was performed on October 15, 2021, therefore, 
this service cannot be verified. Additionally, the records also do not include sufficient documentation to 
validate that an Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access 
sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) was 
performed on October 15, 2021, therefore, this procedure cannot be verified. In addition, CPT 76937 is an add-
on code.  An add-on code is only eligible for payment consideration if and only if one of it's primary codes is 
performed at the same time and is eligible for payment. 
 
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 procedure codes 36620 and 76937 provided to the enrollee on October 15, 2021.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says an IRF admission 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 that the enrollee does not require intensive or complex rehabilitation services to 
recover from a hip fracture. The enrollee 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 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 services are necessary because you require 
additional care before you are able to return home. The Plan denied your request. The Plan says the services 
you need 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 that you have uncomplicated functional loss and weakness due to exacerbation of 
underlying chronic disease when you did obtain her routine outpatient treatment. Your functional status is 
consistent with uncomplicated functional loss managed after an acute exacerbation of chronic disease in a post-
acute setting other than an IRF. You require neither complex nor intensive rehabilitation services 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(CPT code 22514). 
 
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Medicare criteria have not been met. 
 
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 surgery. Our physician reviewer 
found the lumbar fracture occurred eight (8) months ago. It is not a recent fracture. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT code 22514).
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 continuous positive airway pressure (CPAP) 
and bi-level positive airway pressure (Bi-PAP) have been tried and failed, as shown in the medical records. 
You say that failure to adequately treat the enrollee with the requested home ventilator could result in increased 
hospitalizations, serious harm, or death due to elevated carbon dioxide levels. You say that the requested home 
ventilator has alarms and battery backup, and any device without these features is not sufficient. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested device. 
 
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 the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. The enrollee was recently hospitalized with an exacerbation of COPD, and arterial blood 
gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. The provider's appeal note 
indicates BiPAP has failed, but it appears the enrollee improved on BiPAP as an inpatient.  BiPAP was 
reportedly provided at home, but no compliance data is provided, and there is no documentation of failure of 
BiPAP as an outpatient. The enrollee may benefit from BiPAP with average volume-assured pressure support 
(AVAPS) during sleep; there is no evidence this has been tried and failed. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like reconsideration because the 
requested raised toilet seat is medically necessary. The Plan denied your request. The Plan says the requested 
raised toilet seat is not a covered benefit 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and the other 
requested items/accessories (E1002, E2310, E2361, E2607 and E2620). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the record has not addressed the efficacy of a manual wheelchair to allow the enrollee to manage his MRADLs. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (K0856) and the other requested items/accessories (E1002, E2310, 
E2361, E2607 and E2620).