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

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 26, 2021, to July 
30, 2021, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care billed with DRG 682. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not supported as the secondary diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. The Plan argues that DRG 683 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 682. Our 
reviewer says that the secondary diagnosis of sepsis, unspecified organism (A41.9) is not supported in the 
medical record. Our physician reviewer found that the enrollee presented to the facility with the chief 
complaint of dehydration in the setting of nausea and vomiting. Mentation was described as being baseline 
upon presentation. The diagnostic information indicated the enrollee maintained platelets and total bilirubin 
levels within normal limits during the encounter. Creatinine values were cited by the correspondence as 
indication of sepsis; however, the nephrology consult specifically stated the renal failure with elevation in 
creatinine over the baseline of 2.5 was due to dehydration, and not as organ dysfunction related to infection. 
General Medicine notes did not support sepsis until day 2 of admission and it was not clear from the provider 
documentation as to what clinical indicators/features were present beyond the localized infection of the urinary 
tract. The review has determined that the medical records did not support the billing of secondary diagnosis 
sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 682 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 26, 2021, to July 30, 2021, as 
billed with Diagnosis Related Group (DRG) 682.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on August 24, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT code 93352 has a status indicator of M and the 
claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will accept a 
corrected claim for payment reconsideration for all claim lines. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital services provided on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug injection provided on November 5, 
2021. 
 
You asked the Plan to pay for the unclassified drug injection. You say that this drug was used as a medically 
necessary part of the patient's treatment. You say that separate expenses are incurred for this procedure and the 
procedure should be paid. The Plan denied your request. The Plan says payment is included in the global 
surgery package. 
 
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 is drugs unclassified injection. 
  We find that CPT code J3490 is not supported in the medical record. Specifically, CPT code J3490 is excluded 
from payment under the Physician Fee Schedule and considered package into payment for other services under 
the Outpatient Prospective Payment System. This means that CPT code J3490 is not separately payable. Based 
on this information, we decided that Medicare rules for coverage of the unclassified drug injection have not 
been met. Therefore, we decided that the Plan does not have to pay for the unclassified drug injection provided 
on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left atrial appendage closure. 
 
You asked the Plan to pre-approve the left atrial appendage closure. The Plan denied your request. The Plan 
says the enrollee does not meet the coverage criteria. 
 
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 left atrial appendage closure device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee has a CHADS2 VASC score of 2. There is no history 
of bleeding and no apparent contraindication to anticoagulation, but there is concern that he is anemic for 
uncertain reasons. As such, guidelines would not support implantation of a left atrial appendage closure in this 
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 the left atrial appendage closure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the left atrial appendage closure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orchiectomy is a surgical procedure to remove your 
testicles. 
 
You asked the Plan to pre-approve the services. You say that you have pain in your testes. You state you have 
been having significant bothersome side effects from your hormones. The Plan denied your request. The Plan 
says you have not yet seen a therapist as part of the transition process. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have testicular pain and desires to transition physically to the 
female gender. The record does not indicate the presence of testicular pathology that would necessitate the 
requested procedure. The record indicates that you have active psychiatric conditions and have not seen a 
therapist. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve orchiectomy is a surgical procedure to remove your testicles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of gastric stimulator (CPT code 64590). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the criteria states there is no supporting proof that this will work for the enrollee's 
problem, or any other illness. 
 
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 relative to enrollee's presumptive gastroparesis, Tack opines: "In refractory cases, especially 
when there is weight loss, invasive therapeutics such as insertion of feeding tubes, intrapyloric injection of 
botulinum toxin, implantable gastric electrical stimulation, or surgical (partial) gastrectomy are occasionally 
considered, but there is little evidence of efficacy, and these are not devoid of potentially major complications." 
(2)  The American College of Gastroenterology further opines: "gastric electrical stimulation (GES, approved 
on a humanitarian device exemption), does not adequately address clinical need. 
 
 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 replacement of gastric stimulator (CPT code 64590).
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 September 15, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would like this claim to be reviewed and reprocessed for payment. The Plan denied your request. The Plan 
says ambulance transport to or from an outpatient office or facility for or from a scheduled non-urgent visit is 
not a Medicare covered benefit. 
 
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 documentation does not support that the 
ambulance transport on September 15, 2021 was medically reasonable and necessary for the patient. Our 
physician reviewer found the review has determined that the documentation does not support that other means 
of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this patient. Our reviewer also found that the documentation does not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on September 15, 2021. 
 
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 September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gradient compression stocking (CPT code A6530). 
 
You asked the Plan to pre-approve the item. You say that you have a blood clot behind your knee, and this 
would help from it getting worse. The Plan denied your request. The Plan says the item is not covered by 
Medicare or the health plan. 
 
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 item have not been met. The rules say that the following are 
examples of wound care items which are non-covered under the surgical dressing benefit because they do not 
meet the statutory definition of a dressing (not all-inclusive): Gradient compression stockings (A6530, A6533, 
A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6549). Therefore, we decided that the 
Plan does not have to pre-approve the gradient compression stocking (CPT code A6530).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable custom foot inserts (CPT code L3020). 
 
You asked the Plan to pre-approve removable custom foot inserts. You say that the condition is very painful 
when you walk. You state that you also receive shooting pain in your foot from your small toe to your big toe. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve removable custom foot inserts (CPT code L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve a power wheelchair. You say that you cannot walk and carry oxygen. The 
Plan denied your request. The Plan says the wheelchair is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD is only covered under certain medical 
indications.  
 
We looked at the file and the rules. The file shows that the opening to your kitchen and the doorway to the 
bedroom is too narrow. The records do not show that your home provides adequate access between rooms to 
operate the requested wheelchair. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered. The Plan denied your 
request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (P-Stim) (64555). 
 
You asked the Plan to pre-approve the P-Stim. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the following devices are listed under the Food 
and Drug Administration (FDA) approval documents as electro-acupuncture devices used for stimulation of 
auricular acupuncture points and as such are non-covered. Acupuncture for stimulation of auricular points is 
not a covered Medicare benefit. 
     NeuroStim system/NSS 
    P-Stim 
    ANSiStim 
    E-Pulse  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the P-Stim have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Percutaneous implantation of neurostimulator electrode array; peripheral nerve (P-Stim) (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilatory (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilatory. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that products currently classified as HCPCS code E0465, 
E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless 
of the underlying medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible 
for reimbursement for any of the conditions described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. 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 mechanical ventilatory have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a home mechanical ventilatory (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143) and seat attachment (E0156), to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a walker and seat attachment. You say that the service should be covered. 
The Plan denied your request. The Plan says there are in network providers that can provide these items. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a walker (E0143) and seat attachment (E0156), to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 and standard supply allowance. 
 
You asked the Plan to pre-approve the diabetic supplies. You say that it is medically necessary based on type 2 
diabetes mellitus with diabetic nephropathy. 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee is not on insulin-
treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin 
infusion (CSII) pump.  The enrollee's insulin treatment regimen does not require frequent adjustment by the enrollee on the basis of 
BGM or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the 
diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom 
G6 and standard supply allowance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(CPT code 36475). 
 
You asked the Plan to pre-approve the services. You say that you need a debris surgery as well as varicose vein 
surgery because you are in a lot of pain every day, and something needs to be done. The Plan denied your 
request. The Plan says there is no indication you have an adequate blood flow to the leg areas. 
 
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 services. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatment in question. You have documentation of bilateral calf ulcers. These apparently have not responded to 
current treatments including compression and Unna boots. There is no documentation of arterial perfusion to 
the lower extremities in the form of a pulse examination or ABIs. It is not possible to attribute the calf ulcers to 
venous reflux (or the appropriateness of venous ablation) without an assessment of lower extremity arterial 
perfusion. The health plan has noted that in the absence of demonstration of satisfactory arterial perfusion to 
the lower extremities, venous ablative services cannot be covered. This review completely agrees with that 
position. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency; first vein treated (CPT code 36475).