Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more therapy before being 
discharged home. The Plan denied your request. The Plan says that the admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU) treatment of 
the prostate. 
 
You asked the Plan to pre-approve the requested HIFU treatment. You say that it is felt that this treatment 
should be approved. The Plan denied your request. The Plan says the requested treatment is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested HIFU treatment. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a male with Gleason grade 3+4 adenocarcinoma of the prostate 
with baseline prostate-specific antigen (PSA) of 3.2ng/mL. High intensity focused ultrasound of prostrate 
(55880) is not medically necessary and reasonable for the enrollee. The request does not meet national 
guidelines and/or represent standard of care for a patient with this clinical presentation. Current American 
Urological Association (AUA) guidelines state that there is a lack of high-quality data comparing HIFU 
outcomes to radiation therapy, surgery, and active surveillance.   
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 HIFU treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve high intensity focused ultrasound (HIFU) treatment of the prostate.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 the documentation does not support medical necessity for admission to an IRF. 
The enrollee has no medical acuity and no acute rehabilitation nursing needs for an IRF admission. While the  enrollee would benefit from physical therapy and occupational therapy, the enrollees rehabilitation needs can 
be safely met in an alternate and low intensity setting such as in a skilled nursing 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA) of the chest 
(71275) provided on April 21, 2022. 
 
You asked the Plan to pay for the CTA of the chest. You say that you would like this claim to be reconsidered 
and reprocessed for payment. The Plan denied your request. The Plan says more clinical details are needed to 
support the medical necessity for this service. 
 
The Plan follows Medicare rules. Medicare rules say that an MDCT angiography is never covered for 
screening, i.e., in the absence of signs, symptoms or disease.  
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 CTA of the chest. Our reviewer says that 
exam reimbursement should be denied based upon the material submitted. Our physician reviewer found the 
report says the reason or history for the exam is to rule out pulmonary embolism. The requirement for 
appropriate reimbursement of any exam is an appropriate symptom or underlying disease as the indication for 
the requested study. The term "Rule Out" does not qualify and is an inappropriate reason for the exam. Our 
reviewer found that the report shows description of hepatic metastases and prior left pneumonectomy. Our 
physician reviewer also found that based on this report there are most likely appropriate reasons not listed that 
would justify the exam, but such information has not been provided. 
 
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 CTA of the chest have not been met. Therefore, we decided that the Plan 
does not have to pay for the computed tomographic angiography (CTA) of the chest (71275) provided on April 
21, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an insertion of a permanent implantable defibrillator (ICD). 
 
You asked the Plan to pre-approve insertion of an ICD. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an 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 insertion of an ICD. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Medicare rules list no nationally non-covered indications for placement of an ICD. The 
rules also state that This may not be an exhaustive list of all applicable Medicare benefit categories for this 
item or service. You write that, given the constellation of the enrollee not feeling well, then having abrupt 
syncope without prodrome, significant injury with a head contusion... with a depressed left ventricular ejection 
fraction, this scenario is the definition of syncope due to a malignant arrhythmia. The documentation supports 
that insertion of a permanent implantable defibrillator system is medically necessary for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of an ICD have been met. Therefore, we decided that the Plan has to 
pre-approve an insertion of a permanent ICD. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that it is medically necessary that the 
enrollee has a fully electric bed. You need to be able to raise the bed high and low electrically as you cannot 
crank the bed. You are trying to prevent bed sores so he will need a comfortable bed and mattress. The Plan 
denied your request. The Plan says the requested bed is not covered; the height adjustment feature is a 
convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64635) provided on May 11, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 64635 is not supported in the medical record. Specifically, this service is included in the 
10 day global surgery package of another service billed on May 4, 2022. Based on this information, we decided 
that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (64635) provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on April 6, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the service should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 4, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99231) provided on April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 12, 2021, to 
June 16, 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 appropriately and are supported in the medical record. The Plan denied your request. 
The Plan says although they agree the diagnosis of acute respiratory failure with hypoxia is supported in this 
case, the diagnoses of sepsis, unspecified organism (A41.9) and severe sepsis without septic shock (R65.20) are 
not appropriate. 
 
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) and severe 
sepsis without septic shock (R65.20). 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 these diagnoses are not 
supported in the medical record. Our physician reviewer found that the enrollee presented to the emergency 
department on June 12, 2021, with nausea and vomiting. She was diagnosed with a urinary tract infection 
(UTI) and treated with intravenous (IV) fluids and IV antibiotics. Her condition stabilized and improved, and 
she was discharged home on June 16, 2021. In this case there was no clinical or laboratory evidence of sepsis. 
The review has determined that the documentation did not support sepsis, unspecified organism (A41.9) and 
severe sepsis without septic shock (R65.20).  
 
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 12, 2021, to June 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided July 4, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that please review the claim denial for 
accuracy. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the USPS packet shows not delivered and the records do not included evidence that the provider ordered or referred the DME for the enrollee. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided July 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service February 4, 
2022. 
 You asked the Plan to pay for procedure code 97530. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 97530 is bundled into payment for 
code 92526. 
 
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 97530 
is a column II code to column I code 92526. 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 97530 billed for date of service February 4, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 1, 2022 to 
March 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 1, 2022 to 
March 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluations without medical services 
and brief emotional/behavioral assessment provided from June 24, 2022, and June 27, 2022. 
 
You asked the Plan to pay for psychiatric diagnostic evaluations without medical services and brief 
emotional/behavioral assessment. The Plan denied your request. The Plan says the provider is not eligible to 
bill Medicare because provider is a Professional Counselor. A Professional Counselor is not eligible to bill 
Medicare for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program.  Therefore, we decided that the Plan does not have to pay for psychiatric diagnostic evaluations without medical 
services and brief emotional/behavioral assessment provided from June 24, 2022, and June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve a lift chair. 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 a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a lift chair. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have objective 
evidence of severe arthritis of the hip and/or a neuromuscular disease. The seat lift is included in the treating 
practitioner's course of treatment. The seat lift is not likely to effect improvement of the enrollee's condition. 
The records do not show objectively that the enrollee is completely incapable of standing from a chair in the 
home. The document is not specific whether the enrollee is ambulatory. 
 
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 lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055.  
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553). 
 
You asked the Plan to pre-approve the CGM device and supplies. You say that the enrollee is currently 
undergoing chemotherapy for adenocarcinoma and a new diagnosis of diabetes. With undergoing cancer 
treatments and new diagnosis of diabetes, you recommend a continuous glucose monitor. The Plan denied your 
request. The Plan says The clinical information provided does not show that the enrollee meets criteria for the 
requested device and supplies. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM device and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553).