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

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on September 3, 
2021, to September 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. The Plan denied your 
request. The Plan says the billed DRG 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 diagnosis code J96.91. 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 use of diagnosis code J96.91 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented to the emergency department with complaints of shortness of breath 
and a weight gain of 13 pounds. Brain natriuretic peptide was noted to be 14400 and she was treated with IV 
Lasix. Although the provider documented 96.91, Respiratory failure, unspecified with hypoxia, reasonable 
support within the health record must be present for that diagnosis. There was no documentation or respiratory 
failure.  
 
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 the inpatient hospital services provided on September 3, 2021, to September 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services you are requesting 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be provided 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. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary at this time as it would not be 
clinically advantageous. 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (CPT code 64640). 
 
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 Medicare does not cover treatments that are experimental or investigational 
due to unproven safety or efficacy. 
 
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 the use of the Iovera therapy involving the suprascapular nerve would be experimental/ 
investigational and therefore, deemed 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 destruction by neurolytic agent; other peripheral nerve or branch (CPT code 64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arformoterol tartrate (J7605). 
 
You asked the Plan to pre-approve arformoterol tartrate. You say that the requested drug is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Perforomist (formoterol). 
 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 arformoterol tartrate. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arformoterol tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arformoterol tartrate (J7605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0486 provided on January 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure code E0486 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure code E0486 provided on January 5, 
2022, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the doctors you have seen state that you do not need 
to go to a skilled nursing facility, and you need IRF care. You say you need occupational therapy and physical 
therapy to regain function and take care of yourself. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have had a 
functional decline from your baseline level of function, but it is unlikely that you can participate in and benefit 
from the intensity of therapies provided on acute inpatient rehabilitation. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the Colonoscopy, flexible; with directed submucosal injection (45381) 
provided on February 15, 2022. 
 
You asked the Plan to pay for procedure code 45381. You say that the medical records support the billing of 
code 45381. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 45381. 
 
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 45381 is Colonoscopy, flexible; with directed submucosal injection(s), any substance. 
 
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 45381. Our reviewer says that the medical 
records support the billing of code 45381. Our reviewer found provided documentation supports that, in the 
process of tattooing member's colonic mass at 55cm, the colonoscopy service included directed submucosal 
injection of ink. As such, CPT 45381 accurately characterizes the service delivered to member at the time of 
February 15, 2022, colonoscopy. 
 
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 45381 have been met. Therefore, we decided that the Plan has 
to pay for the Colonoscopy, flexible; with directed submucosal injection (45381) provided on February 15, 
2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta 0.024% solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Vyzulta is a self-administered drug, and the medication does not fall under Part B 
coverage. 
 
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 Vyzulta 0.024% solution.   
Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 26, 2020, to October 31, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance 
Prospective Payment System (HIPPS) Score.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 a mechanical soft diet - ground 
meats - was ordered on August 27, 2020. It is documented that the enrollee was "eating/drinking most meals 
and liquids. During the time of service, the documentation in the case file is insufficient to support that the 
enrollee in this case received a mechanically altered diet. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from October 26, 2020, to 
October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that the enrollee has tried cortisone and 
gel injections without relief. You say that the enrollee has tried genicular nerve blocks for diagnostic purposes 
which has helped quite a bit. You also say that your doctor determined that genicular nerve blocks and 
radiofrequency ablation would be the next step to take. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve ablation. Our reviewer 
says that the requested genicular nerve ablation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. Therefore, the 
reviewer found that the requested radiofrequency ablation of the right knee 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
thatthe services are not medically necessary. Our physician reviewer found no clear documentation of a 
qualifying diagnosis is provided, there is no support in the medical record which meets Medicare criteria (Local 
Coverage Determination (LCD): Respiratory Assist Devices - L33800) that the ventilator at issue is medically 
necessary and reasonable for this enrollee. Inadequate details are provided with regard to prior treatment with a 
bilevel positive airway pressure (PAP) device.  
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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 19, 2022, to 
January 29, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for each admission to home health, the HHA 
notifies Medicare systems via submission of an NOA. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the Plan has attested that the only document 
received before the final claim was on Type of Bill (TOB) 0322. This TOB is not correct for an NOA. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 19, 
2022, to January 29, 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 is too complex for skilled 
nursing care at this venue, under the circumstances, poses significant risk for another re-admission. The Plan 
denied your request. The Plan says the services requested for long term acute care hospital have been denied as 
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 the enrollee was admitted to the acute care hospital with endocarditis/sepsis in the 
setting of immune suppression for renal transplant. The course was complicated by acute kidney injury 
requiring bicarb drip, anemia transfusion, and weakness requiring physical and occupational therapy. The 
enrollee required surgical excision of arteriovenous shunt and wound debridement. Recent notes describe the 
enrollee as now with stable vitals but still requiring intravenous antibiotics, bicarb, nephrostomy tube care, and 
basic wound care.  The enrollee appears to be improving and should only require short term additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a spinal condition and require IRF services. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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 most therapy goals have been met, and you would not require intense therapy or 
interdisciplinary rehabilitation in an IRF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the documentation does not support hypercapnic respiratory failure or that 
the use of a bilevel positive airway pressure (BiPAP) device would not meet the enrollee's medical needs. 
 
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 the home ventilator. Our physician 
reviewer found there is no diagnosis for which Medicare covers a home ventilator, specifically COPD, thoracic 
restrictive disease, or neuromuscular disease.  There is no arterial blood gas (ABG) done while stable to 
confirm chronic carbon dioxide (CO2) retention. If the enrollee does have chronic hypoventilation due to 
obesity hypoventilation syndrome (OHS), BiPAP is the appropriate treatment. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).