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

 
We decided that the Plan does not have to pay for a Tenecteplase injection rendered on June 6, 2022. 
 
You asked the Plan to pay for the injection. You say that the submitted medical records support the necessity of 
these services. The Plan denied your request. The Plan says the medical necessity of this drug has not been 
established, and the documentation also does not demonstrate that the injection was received. 
 
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 pay for the injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a diagnosis of  traumatic subdural hemorrhage. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-
approved  drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a Tenecteplase injection rendered on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care (99309) provided on July 19, 2022. 
 
You asked the Plan to pay for the nursing care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records provided do not support the billed service. 
 
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 99309 is Subsequent Nursing Facility Care. 
 
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 nursing care. Our reviewer says that the records provided 
do not support code 99309. Our reviewer found the provided records do not document a detailed history (two 
chronic conditions were reviewed) or moderate decision making. 
 
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 nursing care have not been met. Therefore, we decided that the Plan does 
not have to pay for nursing care (99309) provided on July 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99285) provided on June 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function". 
 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 use of code 99285 is 
not supported by the records provided. Our reviewer found that the documentation does not support medical 
decision making of high complexity. The presenting problems are not of high severity and do not pose an 
immediate significant threat to life or physiologic function. 
 
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 the emergency care (99285) provided on June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee 
osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the role of genicular nerve blocks and of radiofrequency ablation is still the subject of ongoing 
clinical trials. It is considered experimental at this time. Therefore, the request is deemed not medically 
reasonable and 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from September 4, 2021, 
to September 8, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the plan's decision and would like to affirm the original diagnosis codes with further explanation 
and the medical records provided. The Plan denied your request. The Plan says the Payment Integrity post-
service post-pay 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 the review has determined that  the documentation did not support diagnosis code A41.9. The more 
appropriate DRG is 177. In this case, there was no clinical or laboratory evidence of sepsis. In the emergency 
department, the patient was 
noted to be in no respiratory distress and was alert and oriented. The documentation stated, hypotension was 
unspecified and temporary. The patient's creatinine was 1.3 status post fluid with no baseline creatinine 
documented. The patient had a bilirubin of 0.6, a platelet count of 226, a mean arterial pressure of 61, a spO2 
of 88%, and a Glasgow coma scale score of 15.  
 
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 September 4, 2021, to September 8, 2021.
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 will be able to have physical and occupational 
therapy three times a day and that will allow you to progress faster to regain muscle strength, mobility and 
improve your balance to be able to safely return home. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat lift chair (E1399). 
 
You asked the Plan to pre-approve power seat lift chair. You say that you use grab bars in the bathroom and 
has to hold the dresser to get up out of bed, but the nurse did not put that down. You almost fall when trying to 
get out of your current recliner. The Plan denied your request. The Plan says there is no evidence that a power 
seat lift chair is 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 power seat lift chair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the documentation does not indicate that the enrollee has severe 
neuromuscular disease or that they are incapable of standing up from a regular armchair or any chair in their 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 power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power seat lift chair (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 8, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 8, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 

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 pre-approve inpatient psychiatric care from March 
8, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 8, 2023, forward. Our physician reviewer found the enrollee 
did not require inpatient mental health treatment beyond March 8, 2023, as he was not a danger to himself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 
 
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 psychiatric care from March 8, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 8, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
and a specialist office visit provided on December 9, 2022, and December 16, 2022. 
 
You asked the Plan to waive the copayment for a PCP office visit and a specialist office visit. You say that 
your upset because you received a $50 copayment twice in one week after visiting the doctors twice. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $5 
copayment for a PCP office visit. The Plan also clearly says that you must pay a $50 copayment for a specialist office visit. 
 
You have been asked to pay a $5 copayment for a PCP office visit. This service falls within the PCP office visit 
benefit category. You have also been asked to pay a $50 copayment for a specialist office visit, which falls into 
the specialist office visit 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 a primary 
care physician (PCP) office visit and a specialist office visit provided on December 9, 2022, and December 16, 
2022.
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 meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 in this case the enrollee was admitted with infected total hip arthroplasty whose 
hospital course was complicated by atrial fibrillation with rapid ventricular rate and severe anemia. The record 
indicates that the enrollee has ongoing acute medical issues and still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0856) and accessories (E0953, 
E0955, E1002, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the occupational therapy 
wheelchair evaluation clearly confirms and details that the enrollee meets the below criteria as requested. The 
Plan denied your request. The Plan says the enrollee does not have a medical need for single power options 
included with a group 3 power wheelchair. Wheelchair electronics cannot be covered as it is not medically 
necessary to control the requested power options through the joystick. 
 
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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
chronic functional loss. She has no skin breakdown, strong evidence she is not at high risk for skin breakdown. 
She has not had an abrupt or significant decline in function. She does not use a catheter or have spasticity. 
Power drive for recline and/or tilt is not medically necessary. The expandable controller is not medically 
necessary per preceding comments. 
 
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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0856) and accessories (E0953, E0955, E1002, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on May 16, 2022. 
 
You asked the Plan to pay for the services. You say that the emergency ambulance transport was medically 
necessary. The Plan denied your request. The Plan says the information provided does not support criteria for 
air ambulance transport. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
enrollee was diagnosed with a lacerated Achilles' tendon. While transfer to a facility with appropriate services 
to treat the injury as reasonable, the isolated nature of the injury and patients stability meant that the use of an 
air ambulance was not medically necessary. The enrollee could have been safely transferred by ground 
ambulance without an expected decline in her condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on May 16, 
2022.