Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services (88305) provided on October 29, 2021. 
 
You asked the Plan to pay for the dermatology services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not emergent or pre-authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for dermatology services (88305) provided on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary so that the enrollee can regain maximum/prior level of functioning. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate inpatient care at the current hospital and the LTACH would 
offer no additional services to the enrollee. 
 
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 the enrollee appears to be improving but is still somewhat unstable and should 
only require short-term additional acute care services that can be completed at the current facility until more 
stable and more appropriate for a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hyperbaric oxygen therapy provided on 
February 11, 2022. 
 
You asked the Plan to waive the copayment for the hyperbaric oxygen therapy. You say that you would like 
this service covered. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient hospital services. 
 
You have only been asked to pay a $100 copayment for the hyperbaric oxygen therapy which is less than the 
standard $175 copayment. The hyperbaric oxygen therapy falls within the Outpatient hospital services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for hyperbaric oxygen therapy 
provided on February 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuropsychological testing evaluation (96132 and 96133) 
and psychological or neuropsychological test administration (96138) provided on June 25, 2021. 
 
You asked the Plan to pay for neuropsychological testing evaluation (96132 and 96133) and psychological or 
neuropsychological test administration (96138). You say that CPT codes 96132, 96133 and 96138 & are billing 
correctly for neuropsychology services. You say that the time for all services is documented in the attached 
records, which should be reviewed for medical necessity and payment. The Plan denied your request. The Plan 
says appropriate modifiers were not billed with this code pair. 
 
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 96132, 
96133 and 96138 are column II codes to column I code 96020. CPT codes 96132 and 96133 have a modifier 
indicator of 0 and cannot be billed with a modifier to bypass the edit. CPT code 96138 has a modifier indicator 
of 1 and has not been billed with an appropriate modifier to bypass the edit. These column II codes are 
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 neuropsychological testing evaluation (96132 and 96133) and 
psychological or neuropsychological test administration (96138) provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Power Sit To Stand Lift. 
 
You asked the Plan to pre-approve a Power Sit To Stand Lift. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are 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 a Power Sit To Stand Lift. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the documentation doesnt indicate 
that the member is incapable of standing up from a regular armchair or any chair in their home or that once 
they are able to stand they are able to ambulate. 
 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 Power Sit To Stand Lift have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Power Sit To Stand Lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
care is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care 
does not meet criteria. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care was medically 
necessary. Our physician reviewer found on admission was on room air or low dose oxygen without hypoxia, 
without distress. The enrollee was not a candidate for antiviral. He had an acute kidney injury resolved with 
fluids, given steroids, blood cultures with contaminant. Lower level of care more appropriate for the enrollee 
based on the provided documentation. There was no indication that the enrollee would require hospital services 
that would likely cross 2 nights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 a ventilator is medically necessary for the 
enrollee and BiPAP would not be appropriate. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for a home ventilator because BiPAP would meet their needs. 
 
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 the enrollee has chronic 
hypercapneic respiratory failure from chronic obstructive pulmonary disease. The record does not indicate that 
the enrollee has tried and failed the current requested settings administered through a BiPAP device with average colume-assured pressure support (AVAPS) capabilities. The provided primary source documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. The 
enrollee could be treated with a BiPAP machine with AVAPS capability.  The plan has indicated such a device 
is covered.  
 
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 motorized wheelchair. 
 
You asked the Plan to pre-approve a motorized wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item 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 a motorized wheelchair. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the documentation does not support 
that the patient has a mobility limitation that significantly impairs his ability to participate in one or more 
mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. 
 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 motorized wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox (J0585). 
 
You asked the Plan to pre-approve the Botox. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 [e.g., to pay for ... to provide ... to waive the 
copayment for ... ] the Botox. Our reviewer says that the drug is not medically necessary. Our physician 
reviewer found the requested use of Botox injecitons is not FDA-approved for the enrollees diagnosis and its 
use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance used with a therapeutic CGM device 
(K0553) provided December 8, 2021. 
 
You asked the Plan to pay for the supply allowance. You say that kindly find the attached medical records that 
prove the medical necessity and reprocess the claim. The Plan denied your request. The Plan says the records 
do not support that the enrollee meets the medical necessity criteria. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supply allowance. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the plan requires frequent adjustments based on blood glucose level in order to cover the libre. 
We are not told that the doses of Novolog are adjusted based on his blood glucose level. The office notes lists 
the Novolog dose as 20 units with meals. Hence coverage criteria for CGM are not met. 
 
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 supply allowance have not been met. Therefore, we decided that the Plan 
does not have to pay for the supply allowance used with a therapeutic CGM device (K0553) provided 
December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing services. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing services. You say that this genetic 
testing is medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee does 
not have a covered indication for BRCA1 and BRCA2 gene testing. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA genetic testing is subject to the criteria listed 
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 BRCA1 and BRCA2 genetic testing 
services. Our reviewer says that the genetic testing is not medically reasonable and necessary. Our physician 
reviewer found that overage for BRCA1 and BRCA2 genetic testing requires prostate cancer and a family 
history of BRCA, metastatic prostate cancer, or prostate cancer with a PSA of at least 7. This family has no 
family history of prostate cancer, non-metastatic prostate cancer, and a Gleason score of 6. The service is 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 BRCA1 and BRCA2 genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 16, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says required information is missing before this 
claim can be processed. 
 
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 the medical services provided on 
November 16, 2021, have been met. In this case, no medical records were provided to corroborate the services 
as they were billed. Therefore, we decided that the Plan does not have to pay for the medical services provided 
on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission. 
 
You asked the Plan to pay for an inpatient hospital admission. You say that you would like this claim paid due 
to medical necessity. The Plan denied your request. The Plan says medical records were requested and never 
received. 
 
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 an inpatient hospital admission have 
been met. Medical records were requested on multiple occasions and never received. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding formal diagnostic read of the MRI to show Modic type changes at the 
L5 and S1 levels. In this case, there are multiple plausible pathologic sources of significant pain generation. 
Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 1, 2020, to 
November 5, 2020, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 177 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee with functional quadriplegia due to 
multiple sclerosis (MS), suprapubic and transvaginal urethral catheter, ileostomy, and percutaneous endoscopic 
gastrostomy (PEG) tube presented to the emergency department on November 1, 2020, with emesis. She was 
stated to be ill-appearing with leukocytosis and tachycardia present. She answered questions yes or no due to 
MS and was able to follow simple commands. The emergency department physician made a note that the sacral 
decubitus ulcers were unstageable with erosions into the deep tissue purulence noted and foul-smelling from 
the site, so there was a concern of sepsis given that enrollee also had elevated white count and tachycardia. The 
decubitus ulcers were seen by surgery and determined that the decubitus ulcers were not infected, but the 
diagnosis of sepsis was then associated with probable aspiration pneumonia following the vomiting episode 
given the risk factors of MS and PEG tube. The diagnosis of suspected aspiration pneumonia was carried 
through the discharge summary, and the enrollee was noted to improve with treatment with down trending of 
leukocytosis. There was no documentation of clinical sepsis. The review has determined that the medical 
records did not support the billing of sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 1, 2020, to November 5, 
2020, as billed with Diagnosis Related Group (DRG) 871.