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 you are not mobile and believe that inpatient rehab 
services would be more beneficial to you than a skilled nursing facility. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for admission to acute inpatient rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found that your medical problems are stable and there are no nursing or rehabilitation 
needs. 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 documentation does not support medical necessity for admission to an IRF. The 
enrollee has no medical complexity, and no rehabilitation nursing needs other than routine nursing care. While 
the enrollee may benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehabilitation 
needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF). 
 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 the lab services provided on June 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that a more complex drug screening was provided. The 
Plan denied your request. The Plan says the testing is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
March 7, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. Review o f the file shows that the services at issue are identified with 
code 81455. This code is specifically not covered. Based on this information, we decided that Medicare rules 
for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the targeted genomic sequence analysis panel provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223) provided on August 10, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 99223 is Initial hospital care. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this service was within 3 
days of a previous initial hospital care service which was billed for the same diagnosis during the same 
admission. Initial hospital care codes are not appropriate for this service. Based on this information, we decided 
that Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient care (99223) provided on August 10, 2022.
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 are asking for reconsideration of the denial for 
admission to an IRF. The Plan denied your request. The Plan says that the coverage criteria has 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 you do not have complex nursing or rehabilitation needs. 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee needs these injections. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the guidelines require 80% 
pain relief of primary pain. The reviewer found that there was no documentation provided to indicate that this 
was achieved. Therefore, the reviewer found that the requested injections are not 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage. You say that the additional mileage is necessary. The 
Plan denied your request. The Plan says this request is not covered by your Health Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. You are requesting an additional 17 miles for a total of 92 miles. Your benefit only allows 75 miles. Your request exceeds your benefit limit. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, breast, without and with contrast material(s), 
including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic 
analysis), when performed; bilateral (CPT code 77049). 
 
You asked the Plan to pre-approve the breast MRI. You say that the MRI is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met.  
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 breast MRI. Our physician reviewer 
found the requested service is not medically necessary and reasonable, as defined by Medicare rules for the 
diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the local coverage 
criteria are not satisfied. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MRI, breast, without and with contrast material(s), including computer-aided detection 
(CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral 
(CPT code 77049).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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. Medicare rules say that an ILR is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has increased tiredness and 
bradycardia. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. The services are not reasonable or medically necessary at 
this time. 
 
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 implantable loop recorder (ILR).
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 you are appealing this denial. The Plan denied your 
request. The Plan says your records do not show that you need an intensive team approach for your care. 
 
The Plan must follow Medicare rules. The rules say that an 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 there are no complex nursing or rehabilitation needs. While the enrollee may 
need 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 
the 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 an IRF admission and services.
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 LTACH offers the best course of 
treatment. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 should only require short-term additional 
acute care services that can be safely provided at the current hospital facility until more appropriate for 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PET scan of breasts. 
 
You asked the Plan to pre-approve the PET scan. You say that your breasts feel like they are on fire. The Plan 
denied your request. The Plan says the records received due to not indicate a diagnosis of breast cancer or other 
malignancy. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the PET scan have not been met. A PET scan is nationally non-
covered for initial diagnosis and/or staging of axillary lymph nodes. The scan request would be a diagnostic 
scan. Therefore, your appeal request has been denied. Therefore, we decided that the Plan does not have to pre-
approve the PET scan of breasts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an allergist. 
 
You asked the Plan to pre-approve a consultation. You say that the medication you were prescribed by your 
dermatologist has caused you severe itching. You say that you have a rash all over. You say that your 
dermatologist is not able to figure it out. You also say that you do not want to try other antihistamines as you 
have an allergic reaction to them. The Plan denied your request. The Plan says you should consult your 
dermatologist first. The Plan also says that the requested consultation with an allergist 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 consultation. Our reviewer says that 
the requested consultation with an allergist is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record provided does not document exposure to possible allergens as the 
etiology of your itching. The reviewer found the documentation provided is insufficient to establish the medical 
necessity, as defined by Medicare rules, for the enrollee to see an allergist at this time. The documentation 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 consultation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a consultation with an allergist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 5, 2022 to 
February 8, 2022, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the 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 J96.21. 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 submitted records do not support the billing of diagnosis code J96.21. Our physician 
reviewer found the enrollee presented to the emergency department (ED) with shortness of breath and positive 
COVID test taken as an outpatient. She was described as non-toxic and in no acute distress. The lungs were 
clear to auscultation, no wheezes, rales, or rhonchi, and she was normal pulmonary. While it was 
acknowledged that the physician documented the diagnosis of acute and chronic respiratory failure with 
hypoxia, this diagnosis is not sufficiently supported by the medical record documentation. The records do not 
support the billing of diagnosis code J96.21.  
 
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 February 5, 2022 to February 8, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 19, 2021, to 
June 27, 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 reported correctly and are supported in the medical record. The Plan denied your request. The 
Plan says the DRG submitted on this claim 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 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, unspecified organism (A41.9). 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. Our physician reviewer found that 
the enrollee presented to the emergency department with abdominal pain. She was evaluated and diagnosed 
with sigmoid diverticulitis. Her vital signs were stable with white blood cell count elevated to 18.9. She was 
treated with intravenous (IV) fluids, bowel rest and IV antibiotics. She developed Clostridium difficile colitis 
and required treatment with Vancomycin. Per Medscape Internal Medicine, sepsis is a life-threatening 
syndrome usually caused by bacterial infection. Sepsis is a response of the body's immune system that results 
in organ dysfunction or failure. The systemic inflammatory response syndrome (SIRS) criteria were recently 
replaced by the quick Sequential Organ Failure Assessment (qSOFA) in 2016, allowing for quick bedside 
analysis of organ dysfunction in patients with suspected or documented infection. The qSOFA score includes a 
respiratory rate of 22 breaths/minute or more, systolic blood pressure of 100 mm Hg or less, and altered level 
of consciousness. For completeness, severe sepsis is defined as sepsis complicated by organ dysfunction. In 
this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the diagnosis 
of sepsis, unspecified organism (A41.9) was not supported in the medical record.  
 
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 19, 2021, to June 27, 2021, at the Diagnosis Related Group 
(DRG) originally billed.