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

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve Nuplazid. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid.  
 
Benefits for Nuplazid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for enrollees that 
do not receive adequate relief from traditional conservative methods and do not have instability to indicate 
fusion is appropriate. The Plan denied your request. The Plan says the clinical effectiveness and value have not 
been demonstrated. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 5, 2022, to 
May 10, 2022. 
 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 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 177. 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 the enrollee presented to the emergency department with leg swelling and shortness of breath. The enrollee 
was diagnosed with acute congestive heart failure and treated with diuresis. The computed tomography (CT) of 
the chest showed evidence of pneumonia and antibiotics were initiated. However, the provided documentation 
did not reveal any evidence of a gram-negative organism causing the pneumonia to justify the specific code, 
J15.6. There was no sputum or blood sample revealing this organism being present. Therefore, the more 
appropriate DRG is 193.  
 
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 rendered from May 5, 2022, to May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thoracoscopy, surgical; with pleurodesis rendered on August 
9, 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 thoracoscopy with pleurodesis is inherent to the thoracoscopy with parietal pleurectomy. The 
two procedures were performed at the same anatomic site. 
 
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 32650 is "Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical)." 
 
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 the appropriate use of the 59 modifier to unbundle the 
relationship between CPT codes 32650 and 32656. The medical records provided does not validate that 32650 
was performed as a distinct separate service unrelated to CPT 32656, therefore the use of the 59 modifier is not 
appropriate. 
 
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 thoracoscopy, surgical; with pleurodesis rendered on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee brace (L1851). 
 
You asked the Plan to pre-approve the knee brace. 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 the criteria listed in the Medicare Rules section must 
be met for a knee brace to be 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 knee brace. Our reviewer says that 
the member does not need this item. Our physician reviewer found the enrollee has not had surgery or recent 
injury and has no instability. 
 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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee brace (L1851).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 28, 2022, to 
April 30, 2022. 
 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 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 872. 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 the fever alone in this case could explain the tachycardia. Renal impairment and hypotension secondary to 
sepsis may not be diagnosed in setting of volume depletion. The enrollee's condition did not meet criteria for 
sepsis. The DRG was correctly adjusted based on the enrollee's condition.  
 
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 rendered from April 28, 2022, to April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral sacroiliac joint injections (27096).  
You asked the Plan to pre-approve the bilateral sacroiliac joint injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the 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 the bilateral sacroiliac joint injections. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation on physical examination of three (3) or more 
positive tests results. The clinical value and effectiveness of an SIJ injection in the absence of tenderness and 
negative provocative testing results has not been demonstrated in the peer-reviewed literature. 
 
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 bilateral sacroiliac joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the bilateral sacroiliac joint injections (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left-sided L5-S1 microdiscectomy procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had an adequate trial of non-surgical management. 
 
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 services. Our physician 
reviewer found that the enrollee is being treated for spondylosis with radiculopathy of the lumbar region and 
intervertebral disc displacement of the lumbar region. She was bending over about a month ago and felt a pop 
in her back and had immediate left-sided buttock posterior thigh and calf pain. She is a current everyday 
smoker. The exam reveals markedly positive straight leg raise on the left side. She is slow to stand from the 
sitting position without the use of her arms, but she can do so and slowly stands upright as well. Detailed 
documentation is not evident regarding a trial and failure of recent, reasonable, comprehensive less invasive 
conservative care measures. The treatment plan on the exam was for an epidural steroid injection. This is not 
clearly documented to have been completed (with failure to improve symptoms).  There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the request for 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left-sided L5-S1 microdiscectomy procedure.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 30, 
2022. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed is not supported. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient , which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
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 emergency room visit. Our reviewer says that the records do not support the billed code. Our reviewer found records show there was no medical decision making of high 
complexity. 
 
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 emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit (99285) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has continued worsening of chronic 
hypercapnic respiratory failure. You say that despite bi-level positive airway pressure (BiPAP) and oxygen, the 
enrollee remains hypoxic with hypoventilation. You also say that the enrollee will need non-invasive 
ventilation therapy with target tidal volume and assure exhalation to resolve. The Plan denied your request. The 
Plan says ventilators used to provide continuous positive airway pressure (CPAP) or bi-level positive airway 
pressure (BiPAP) therapy is not reasonable and necessary. 
 
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 ventilator. Our reviewer says that an 
in-home ventilator is not medically necessary. Our physician reviewer found the provided documentation does not indicate a pulmonary function test has been done to confirm the chronic obstructive pulmonary disease 
(COPD) diagnosis, and no arterial blood gas (ABG) has been done while stable to document chronic carbon 
dioxide (CO2) retention. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. Therefore, the reviewer found that the requested in-home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has dementia and he deteriorated since 
being in the hospital, only had physical therapy 4 times, and needs occupational therapy as well. The Plan 
denied your request. The Plan says the enrollee's records do not show skilled nursing daily in an inpatient 
setting, services required can safely be received at a different setting, at home with home health, in residential 
care, or home with close follow-up with your doctor.  
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the enrollee needs nurses care and 
equipment which other facilities in the area do not have, the enrollee is in the hospital and needs urgent care, 
currently inpatient and needs to continue treatment. The Plan denied your request. The Plan says the enrollee's 
medical conditions are not sufficiently complex to require LTAC level of care, the care needed can be safely 
managed in a lower-level setting like skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital. 
 
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: 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 the services are necessary for the 
enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee can safely receive 
this care in another setting such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is not yet stable for transfer and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on 
June 9, 2022, to June 14, 2022. 
 
You asked the Plan to pay for an acute inpatient psychiatric hospitalization. You say that this inpatient stay was 
medically necessary. The Plan denied your request. The Plan says the medical criteria for an acute inpatient 
psychiatric hospitalization have not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric 
hospitalization. Our reviewer says that an acute inpatient psychiatric hospitalization was not medically 
necessary. Our physician reviewer found based upon review the records provided for the admission of this 
enrollee does not meet the criteria for June 9, 2022, forward as this enrollee was not shown to be a danger to 
herself or others, delusions, auditory or visual hallucinations noted. She was cooperative/compliant with 
treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided on June 9, 
2022, to June 14, 2022.