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 January 12, 2022, 
to January 20, 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. 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 N17.0. 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 N17.0 is not supported by the records provided. Our physician 
reviewer found that the enrollee has a diagnosis of chronic kidney disease stage IIIB with a baseline creatinine 
of 1.89. Her creatinine was 5.2 on admission and Glomerular Filtration Rate (GFR) was 9.9. Collected 
urinalysis did not have any lab abnormalities consistent with the diagnosis of acute tubular necrosis (ATN) 
such as non-hyaline (granular or muddy casts). The was no Urinary sodium noted in chart documentation for 
review. No FeNA criteria available to review. There was no documentation to support a diagnosis of ATN. The 
use of diagnosis code N17.0 was not supported by the records provided.  
 
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 January 12, 2022, to January 20, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve coronary intravascular brachytherapy. 
 
You asked the Plan to pre-approve the requested coronary brachytherapy. You say that this is a medically 
necessary treatment for the stent that has re-stenosed. The Plan denied your request. The Plan says that 
radiation therapy has been requested for a non-cancer condition. It was found that the wrong codes were used 
so the services cannot be approved. 
 
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 requested coronary brachytherapy. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 73-year-old male with recurrent in-stent re-stenosis. The 
enrollee recently underwent successful percutaneous coronary intervention (PCI), with planned use of prasugrel 
through 12/2023. It is not clear when the physician would like to implement the brachytherapy, now or in the 
future in the event the recently performed PCI were to re-stenose. It is reasonable to perform coronary 
intravascular brachytherapy for recurrent in-stent restenosis. 
 
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 requested coronary brachytherapy have been met. Therefore, we decided 
that the Plan has to pre-approve coronary intravascular brachytherapy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00790 provided on May 13, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 00790 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as code 00811 (anesthesia). If multiple procedures are performed on the same date of 
service, the provider should indicate the separately identifiable sessions using specific modifiers. One of these 
modifiers was not billed with this claim. This means the claim is not payable as submitted. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00790 provided on 
May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tesla BioHealing device. 
 
You asked the Plan to pay for the Tesla BioHealing device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose and is available to 
the general public and would be helpful even to those who are not sick or injured. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the Tesla BioHealing device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches to 
treatment. The Plan denied your request. The Plan says the safety and efficacy of this procedure has not been 
established. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on July 2, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you were unable to take a taxi because you could not hear anything. You also say that you took the ambulance 
because you thought it would be covered by your insurance. The Plan denied your request. The Plan says the 
information received does not meet criteria because at the time of service, you did not have any condition that 
endangered your life if other modes of transportation were used to get you from the hospital to home. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the ambulance transportation from the emergency 
department to your residence was not medically necessary. Our physician reviewer found you were not 
bedbound. You did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Our reviewer found that transportation could have been 
provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering your condition. 
Our physician reviewer also found that a prudent layperson would not believe that immediate medical attention 
was required for someone who was being discharged home from the emergency department. 
 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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on August 8, 2022. 
 
You asked the Plan to pay for the new patient office visit. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a new patient office visit provided on August 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tenex percutaneous tenotomy of hip abductor or 
extensor (27299). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you would like to try this procedure to 
provide the enrollee with long lasting pain relief and to prevent multiple returns to the clinic for other 
procedures. The Plan denied your request. The Plan says the Tenex percutaneous ultrasound-guided tenotomy 
is considered investigational or experimental. There has not been enough research done to prove that this 
procedure is effective and/or expected to improve your hip pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve Tenex percutaneous tenotomy of hip abductor or extensor (27299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had two documented falls with 
injury in the last week due to their severe weakness and fatigue. You say the enrollee is entitled to IRF benefits 
to increase their endurance and to help reduce their high fall risk. The Plan denied your request. The Plan says 
the enrollee does not meet medical necessity criteria for admission to an IRF. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 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 referring provider 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 the laboratory services provided on April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 87503, 87632, & 87634 billed for date of 
service January 11, 2022. 
 
You asked the Plan to pay for procedure codes 87503, 87632, & 87634. You say that this service was 
medically necessary. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87632. Codes 87503, & 87632 do not meet coverage rules. 
 
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, we have confirmed that code 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Codes 87503, & 
87632 were for testing of 5 or more respiratory pathogens. This service is not covered. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87503, 87632, & 87634 billed for date of service 
January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says studies have not proven that this procedure is helpful for 
the enrollee's health problem. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you need this service to be covered due to a 
possible medical decision of Alzheimer's disease, and you would like to verify the diagnosis with the scan. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan. Our reviewer says that you 
do not meet the criteria for coverage for a PET scan. Our physician reviewer found the record indicates that 
you have mild cognitive impairment and likely Alzheimer's disease. The records provided do not indicate that 
you meet the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia. Our reviewer found 
that the records do not document that the requested examination is being performed in the context of a clinical 
trial. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the 
requested service is not 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that this ventilator is medically 
necessary to keep the enrollee out of the hospital. The Plan denied your request. The Plan says the ventilator 
requested does not meet the requirements for approval. 
 
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 non-invasive home ventilator. Our 
reviewer says that a home ventilator is not medically necessary. Our physician reviewer found this enrollee has 
obstructive sleep apnea (OSA), on continuous positive airway pressure (CPAP). The medical note mentions 
restrictive lung disease, but pulmonary function test results are not provided. Our reviewer found there is no 
diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. There is an arterial blood gas (ABG) 
test showing mild carbon dioxide (CO2) retention, but the circumstances are not provided. Our physician 
reviewer also found that if this enrollee has chronic CO2 retention, they may benefit from bilevel positive 
airway pressure (BiPAP) during sleep. However, Medicare does not cover a home ventilator for the treatment 
of OSA, 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 non-invasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291.  
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, we have confirmed that code 93042 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 PACE Program center days per week. 
 
You asked the Plan to pre-approve PACE center days. You say that the enrollee's needs have increased since 
before the pandemic while they are receiving less services. You say that the enrollee still requires physical 
therapy for movement. You also say that the enrollee is isolated in their room. The Plan denied your request. 
The Plan says the requested services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 PACE center days. Our reviewer says 
that the requested PACE center days are not medically necessary. Our physician reviewer found the 
documentation does not sufficiently support that the requested services are necessary and reasonable to meet 
your needs and to improve and maintain your overall health status. The reviewer found that you already have 
these opportunities available at no extra cost at the assisted living facility. The reviewer found that the 
requested services are not experimental. the reviewer also found that the requested services are not cosmetic. 
Therefore, the reviewer found that the requested PACE center days 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 PACE center days have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 2 PACE Program center days per week.