Persius/hicric huggingface dataset:
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 
August 14, 2021, to August 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for The Plan denied your request. 
The Plan says the billed condition did not qualify for reporting.  
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 193 (SIMPLE PNEUMONIA AND 
PLEURISY WITH MCC). 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 supported by the medical records. Our physician 
reviewer found that the review has determined that the record did not support that J96.21 - acute on chronic 
hypoxic respiratory failure - was an appropriate diagnosis for this case. The appropriate DRG was DRG 194: 
SIMPLE PNEUMONIA AND PLEURISY WITH CC.  
 
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 August 14, 2021, to August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99203, 99213) with a pain management 
specialist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you are running out of your medication and the 
in-network specialist wont be able to see you until October. The Plan denied your request. The Plan says out 
of network services are not available when in network providers are available to provide medically necessary 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99203, 99213) with a pain management specialist to be provided by an out-of-network (OON) 
provider.
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 acute inpatient 
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute 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 requested acute inpatient hospital care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found the enrollee is undergoing a planned 
elective right shoulder surgery. The enrollee is medically stable with a past medical history of hypertension and 
rheumatoid arthritis. The planned procedure listed under CPT codes 23472 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Jardiance.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or 
bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610). 
 
You asked the Plan to pre-approve an injection. You say that you were scheduled for surgery to alleviate knee 
pain, you have opted to not have the surgery and instead choose to have the injection to alleviate pain in your 
knee. The Plan denied your request. The Plan says the request does not meet medical requirements. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of physical therapy or other NSAID medications for knee pain. More 
conservative measures for knee djd are 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 an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, 
subacromial bursa); without ultrasound guidance (20610).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection, anesthetic agent and/or steroid, transforaminal epidural; 
lumbar or sacral, single level (64483) injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar 
or sacral, each additional level (List separately in addition to code for primary procedure) (64484). 
 
You asked the Plan to pre-approve the 2 epidural injections. You say that you were under the impression the 
doctor would file the appeal for you. However, you found out that they did not file the appeal. The Plan denied 
your request. The Plan says that the clinical information provided does not include a treatment plan with the 
spinal levels to be treated. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pre-approve the 2 epidural injections. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the LCD limits the number of levels to 2 per session. Therefore, the third level is 
deemed not medically reasonable and necessary.  The other two levels are 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 2 epidural injections have been met. Therefore, we decided that the Plan has 
to pre-approve injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level 
(64483) injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional 
level (List separately in addition to code for primary procedure) (64484).  
 
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: 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 all of the physicians involved with the 
enrollee concur that LTACH is the appropriate level of care and that he is medically stable for transfer. You 
say that the enrollee is still trach dependent and is too medically complex for a lower level of care. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to an LTACH. 
 
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 was admitted to the acute care hospital with acute respiratory failure 
related to supraglottal mass requiring trach and G-tube placement. Recent notes describe the enrollee with 
stable vitals, tolerating tube feeds, and on low dose oxygen support via trach and with plans for considering 
outpatient chemotherapy/radiation therapy or surgery. The enrollee appears to be more stable and improving 
and should only require short-term additional acute care services that can be safely administered at the current facility until more 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. Transfer to LTACH is not medically necessary as it would 
not be clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 an oxygen concentrator and portable oxygen.  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
obstructive sleep apnea (OSA), and dyspnea. The most recent information dated February 7, 2022 indicates an 
SpO2 of 95 percent on breathing room air, which does not indicate a need for oxygen. The services are 
therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator and portable oxygen.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emotional support animal. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. The contract 
with the Plan covers a $500 allowance per calendar year for canine food and supplies for an ADA service dog 
when supporting documentation is received. 
 
We looked at the file and Medicare rules. The file shows that an emotional support animal is being requested. 
This is not covered by Medicare. The supplemental benefit with the Plan covers up to $500 per calendar year 
for the purchase of canine food and supplies only for members with an ADA service dog and cannot be used to 
purchase a service animal itself. Furthermore, the emotional support animal is not an ADA certified service 
animal. Therefore, we decided that the Plan does not have to pre-approve an emotional support animal.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radicava ORS. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Radicava ORS.  
 
Benefits for these services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided March 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you needed help after a fall. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have obesity-hypoventilation 
syndrome, with a recent hospitalization for acute on chronic hypercarbic and hypoxemic respiratory failure. 
You improved in the hospital. There is no diagnosis of severe COPD, thoracic restrictive disease, or 
neuromuscular disease. You may benefit from cpap or bipap during sleep, but Medicare does not cover a home 
ventilator for your diagnosis, or when used as bipap. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echo guide for biopsy services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON echo guide for biopsy services. You say that the requested services 
are medically necessary. The Plan denied your request. The Plan says there are four facilities in the enrollee's 
area who are in network and able to perform an echo guide for biopsy services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an echo guide for biopsy services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 49020) provided to the 
enrollee on February 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains 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 49020 is "Drainage of peritoneal abscess or localized 
peritonitis, exclusive of appendiceal abscess, open." 
 
 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 operative report describes 
drainage of abscess in the same location as the primary procedure. Therefore, this procedure would not be 
reported separately and modifier -59 would not be supported. When work is substantially greater than typically 
required, a more appropriate modifier would be reported. The documentation does not support a separate and 
distinct procedure. 
 
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 surgical services (procedure code 49020) provided to the enrollee on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchodilation responsiveness, spirometry, pre-and-post-
bronchodilator administration provided to the enrollee on April 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a procedural modifier is required, per Medicare guidelines. 
 
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 94060 is "Bronchodilation responsiveness, spirometry as 
in 94010, pre- and post-bronchodilator administration." 
 
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 supported by the medical records. Our reviewer found that the provider performed a repeat 
procedure on the same date of service. In this case, there is an appropriate modifier that would be appended for 
the same test repeated on the same day of service. 
 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 bronchodilation responsiveness, spirometry, pre-and-post-bronchodilator administration 
provided to the enrollee on April 7, 2021.