Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness upgrade, electronic 
connection between wheelchair controller and two or more power seating system motors, and power seat 
elevation system. 
 
You asked the Plan to pre-approve an expandable controller, harness upgrade, electronic connection between 
wheelchair controller and two or more power seating system motors, and power seat elevation system. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is specifically not 
covered. Review of the file shows the enrollee has no pressure sores and does not require intermittent 
catheterization. The enrollee requires a Hoyer lift for all transfers. The documentation shows that the enrollees 
caregivers operate the enrollee's Hoyer lift for transfers, so caregivers have upper limb strength and function 
are adequate to control the power options using their own switches which are included in the allowance of 
these power options. 
 
Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness 
upgrade, electronic connection between wheelchair controller and two or more power seating system motors, 
and power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller, harness upgrade, electronic connection between wheelchair controller and 
two or more power seating system motors, and power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift (E1399). 
 
You asked the Plan to pre-approve a stair lift. You say that you feel that the stair lift for your home staircase 
should be a covered item because you are prone to falling. Your spouse will be going out of town for a long 
period of time and you wont have anyone there to make sure you wont fall. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).
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 IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care 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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extended respiratory pathogen panel (87503, 87632 and 
87634) provided on June 16, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that these services were necessary and 
are supported in the medical record. The Plan denied your request. The Plan says these services were not 
reported in accordance with Medicare billing guidelines. The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. 
 
We looked at the file and Medicare rules. The respiratory panel in this case was unbundled and billed as 
individual components. Based on this information, we decided that Medicare rules for coverage of the 
respiratory pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for an 
extended respiratory pathogen panel (87503, 87632 and 87634) provided on June 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97112, 97530 and 97535) provided on 
August 4, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services should be resubmitted with the KX modifier in order to be 
processed for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the KX modifier should 
be used as a confirmation that services are medically necessary after the beneficiary has exceeded the KX 
modifier threshold of incurred expenses. If a claim is submitted without KX modifiers and the cap is exceeded, 
those services will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the record shows that the enrollee in question has 
exceeded the KX modifier threshold of incurred expenses, but the KX modifier was not used on the 
claims/services at issue. Therefore, we decided that the Plan does not have to pay for therapy services (97112, 
97530 and 97535) provided on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the disposable liner/shield/guard/pad/undergarment, for 
incontinence, each (T4535). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you feel that the underpads should be 
covered by the Plan. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the disposable 
liner/shield/guard/pad/undergarment, for incontinence, each (T4535).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that a sacroiliac joint injection is 
medically necessary. The Plan denied your request. The Plan says a sacroiliac joint injection 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 a sacroiliac joint injection. Our 
reviewer says that the requested sacroiliac joint injection is not considered medically reasonable and necessary. 
Our physician reviewer found that sacroiliac joint (SIJ) injections are recommended as an option if the patient 
has failed at least 4-6 weeks of aggressive conservative therapy including, physical therapy (PT), home 
exercise and medication management. There should be evidence of a clinical picture that is suggestive of 
sacroiliac injury and/or disease. At least three (3) positive exam findings of SI joint dysfunction should be 
present on physical exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's 
test.   
 In this case, there is no documentation on physical examination of three (3) or more positive tests results. The 
clinical value and effectiveness of an SI joint injection, in the absence of tenderness and negative provocative 
testing results, have 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 a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 10, 2021, to 
June 14, 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 these 
services were all reported appropriately and are supported as billed. The Plan denied your request. The Plan 
says the DRG submitted on this claim is not supported. 
 
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 sepsis due to Escherichia coli (A41.51). 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 this diagnosis is not supported in the medical record as reported. Our physician 
reviewer found that the documentation does not consistently and completely support the assigned principal 
diagnosis code with this DRG. The replacement of DRG is upheld as it is supported by the medical 
documentation. 
  
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 June 10, 2021, to June 14, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
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 the enrollee is ready to be discharged from the 
hospital and into an IRF. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can safely receive the services they need in other settings. 
 
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 meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services at 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 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 a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you are on blood thinners and lancing 
your finger on the non-dominant hand has become very difficult. The Plan denied your request. The Plan says 
you do not meet criteria for the requested device. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization program (PHP) level of care. 
 
You asked the Plan to pre-approve partial hospitalization program. You say that this is needed due to the 
enrollee's symptoms. The Plan denied your request. The Plan says a partial hospitalization program is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a partial hospitalization program may be covered 
under certain clinical circumstances. 
 
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 partial hospitalization program. Our 
reviewer says that the enrollee does not meet criteria for a partial hospitalization program. Our physician 
reviewer found the enrollee was not showing any dangerousness to self or others and has not been exhibiting 
severe psychological or psychiatric impairment requiring this level of care. The enrollee does not have any 
suicidal or homicidal thoughts or behavioral disturbances that would interfere with multiple areas of daily life. 
The enrollee could be treated at 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 partial hospitalization program have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial hospitalization program (PHP) level of care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided July 12, 2021, to July 16, 
2021 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that an admission was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee required close observation due to high risk of perianal abscesses turning more 
dangerous and emergent. Additional time was needed after aspiration and antibiotics to ensure improvement 
prior to discharge.  
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided July 12, 2021, to July 16, 2021  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Johnson & Johnson DePuy Synthes ViviGen Allograft 
allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Johnson & Johnson DePuy 
Synthes ViviGen Allograft in the setting of anterior lumbar interbody fusion has not been demonstrated in the 
peer-reviewed literature. The Plan states there is no documentation that the enrollee is participating in a clinical 
trial or study to support an exception. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Johnson and Johnson DePuy Synthes ViviGen Allograft, in 
this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Johnson & Johnson DePuy Synthes ViviGen Allograft allograft (CPT code 20930).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 7, 2022, to 
March 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from February 7, 2022, to 
March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
23, 2021, to June 28, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the removal of the diagnosis codes and change 
in DRG is based on lack of supporting clinical evidence from the medical record provided. 
 
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 189. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of respiratory failure. The review has determined 
that the records did not support the reporting of DRG 189 in this case. The records did not support the use of 
diagnosis code J96.01 - acute respiratory failure with hypoxia - in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 23, 2021, to June 28, 2021.