Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for sacral pressure ulcer. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87471 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 87471. You say that these services were necessary and were 
ordered by your doctor. The Plan denied your request. The Plan says they have agreed to pay for the laboratory 
services; however, the service billed with code 87471 is not supported in the medical record. 
 
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 87471 is infectious agent detection by nucleic acid (DNA 
or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique. 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 procedure code 87471. Our reviewer says that the record 
does not support that code 87471 qualifies for reporting in this case. Our reviewer found the laboratory results 
do not contain evidence that nucleic acid detection was performed for Bartonella henselae and Bartonella 
quintana; there are not test results for both infectious agents in the record. The criteria for reporting 87471 have 
not been met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87471 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87471 billed for date of service October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 18, 2022, to 
March 23, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documents support the originally billed DRG. The Plan denied your request. The Plan says the records do not 
support diagnosis codes A40.8 and A41.89. 
 
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 with diagnosis codes A40.8 and A41.89, defined as other 
streptococcal sepsis and other specified sepsis. 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 documentation does not 
support the assigned secondary diagnoses codes. Our physician reviewer found there was no evidence of life-
threatening organ dysfunction due to a dysregulated host response to an infection or persistent hemodynamic 
instability.  
 
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 from March 18, 2022, to March 23, 2022, at the DRG originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arterial catheter placement and associated inpatient 
admission 
 
You asked the Plan to pre-approve an arterial catheter placement and associated inpatient admission.. You say 
that the enrollee needs this service for atherosclerotic heart disease. The Plan denied your request. The Plan 
says based on the clinical information we received, your request 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 an arterial catheter placement and 
associated inpatient admission. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollees left 
ventricular ejection fraction is 50-55% and the patient does not have NYHA Class IV heart failure. As such, 
guidelines for placement of a left ventricular assist device (LVAD) in this setting are not met. In summary, 
there is insufficient documentation to support the medical necessity for LVAD placement in this enrollees 
clinical management. Since the arterial catheter placement is determined to be not medically necessary, the 
associated inpatient admission is also denied.  
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 arterial catheter placement and associated inpatient admission. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an arterial catheter placement and 
associated inpatient admission
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the item is necessary. The Plan denied your request. The 
Plan says the requested item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), comprehensive oral evaluation - new or 
established patient (D0150), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) 
provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought you would be covered by this 
provider. You also say that the provider told you they were in-network. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), comprehensive oral evaluation - new or established patient (D0150), bitewings - 
four radiographic images (D0274) and prophylaxis - adult (D1110) provided on September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 17, 2022, to 
May 23, 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 diagnosis codes A41.51 and A41.52. 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 was admitted to the hospital with weakness, in the setting of 
lymphoma and active chemotherapy. The enrollee subsequently developed sepsis and was found to have E. coli 
in her blood and Pseudomonas in her urine. Consequently, a principal diagnosis of sepsis due to E. coli is 
warranted, with a secondary diagnosis of urinary tract infection due to pseudomonas. The codes as billed are 
not supported.   
 
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 17, 2022, to May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous carotid artery stenting (PCAS) (37215). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. Medicare rules say that a percutaneous transluminal angioplasty is covered 
under indicated conditions.  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary.   
Our physician reviewer found that at issue is the appropriateness and medical necessity of percutaneous carotid 
artery stenting (PCAS) of this enrollee's bilateral carotid disease. The enrollee would appear to be a suitable 
candidate for surgical endarterectomy. This service is not medically necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous carotid artery stenting (PCAS) (37215).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve ondansetron. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says oral anti-emetic drugs that are not administered with 
chemotherapy treatment and initiated within 2 hours of the administration of chemotherapy 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 ondansetron.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis, abduction positioning, 
airplane design, prefabricated, includes fitting and adjustment rendered on August 12, 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 Healthcare Common Procedure Coding System (HCPCS) code L3960 GA LT (1 Unit) 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 Healthcare Common Procedure Coding System (HCPCS) 
L3960: is "Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes 
fitting and adjustment." 
 
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. Our reviewer found that the procedure report does include documentation of a 
brace, but does not specify the exact kind of brace. Therefore, this code cannot be verified.  
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 a shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, 
includes fitting and adjustment rendered on August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not 
tried and failed the required drugs. There is no documentation provided indicating that the Plans required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure ( 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this procedure 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the case file does not contain documentation of Modic changes at the proposed levels 
for the Intracept procedure in this case. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee had a severe reaction to Venofer. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
Plan requires a trial of drug Infed and Venofer before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa injections (J7323). 
 
You asked the Plan to pre-approve the Euflexxa injections. You say that this service is medically necessary. 
The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this treatment will only be covered for the treatment 
of pain in osteoarthritis of the knee when medically necessary. There must be a trial of conservative therapy. 
 
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 Euflexxa injections. Our reviewer 
says that this injection is medically necessary. Our physician reviewer found the rules do not require Tylenol or 
bracing when the enrollee has failed other conservative therapy. The viscosupplementation for this patient is 
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 the Euflexxa injections have been met. Therefore, we decided that the Plan has 
to pre-approve Euflexxa injections (J7323).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in immediate need of this 
device, which helps prevent pulmonary infections, hospitalizations, or the need for antibiotics. The enrollee has 
a diagnosis of chronic hypercapnic respiratory failure, obstructive sleep apnea, chronic obstructive lung 
disease, asthma, gastroesophageal reflux disease, history of pulmonary embolism. chronic obstructive 
pulmonary disease, morbid obesity, hypoventilation syndrome, and oxygen dependence. The Plan denied your 
request. The Plan says claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) which 
could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up 
rate. As stated in the Local Coverage Determination (L33800), Claims for ventilators used to provide CPAP 
or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).