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

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from September 18, 
2021, through October 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 J15.6. 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 services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee presented with difficulty urinating and urinary retention. The initial testing 
revealed urinary tract infection. The enrollee was treated with antibiotics and fluids, and was admitted. The 
enrollee was also treated for acute kidney injury and congestive heart failure during the hospital stay. Chest 
imaging revealed evidence supporting pneumonia. However, no sputum culture or other identifying evidence to 
show a gram-negative bacteria was present causing the pneumonia to support the diagnoses of pneumonia from 
gram negative bacteria (J15.6).   
 
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 rendered from September 18, 2021, through October 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDX Melanoma testing (81529) provided on June 14, 
2021. 
 
You asked the Plan to pay for DecisionDX Melanoma testing. You say that this testing was denied and should 
be paid as a covered benefit. The Plan denied your request. The Plan says there is no indication that the 
enrollee had been evaluated for metastatic disease, nor that there was documented concern about the adequacy 
of microstaging 
 The Plan follows Medicare rules. Medicare rules say that this testing is covered for enrollees with a personal 
history of melanoma and have T1a with documented concern about adequacy of microstaging 
 
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 DecisionDX Melanoma testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee's tumor is 
stage T1a. There is no indication that the enrollee had been evaluated for metastatic disease, nor that there was 
documented concern about the adequacy of microstaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DecisionDX Melanoma testing have not been met. Therefore, we decided that 
the Plan does not have to pay for DecisionDX Melanoma testing (81529) provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be improving with current treatment and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device. 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Minuteman G3R Interspinous device at L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (eo), with adjustable position locking 
joint(s), prefabricated, off-the-shelf provided to the enrollee on July 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation provided does not support the need for the elbow orthosis. The prescription for 
the orthosis indicates a diagnosis of right sided elbow pain but the clinical documentation is insufficient in 
terms of the patients clinical history regarding elbow pain. There is no noted deformity or lack of instability of 
the elbow joints on the physical examination. Therefore, the requested elbow orthosis is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf 
provided to the enrollee on July 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that based on the additional information available, the request does not meet the 
Medicare or health plan coverage criteria. 
 
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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that for metastatic disease, SBRT is generally indicated for patients with oligometastatic disease of for 
those undergoing palliation after prior radiation to the same site. Based on American Society for Radiation 
Oncology (ASTRO) model policy, and data supporting better outcomes with SBRT for bone metastases, SBRT 
for limited sites of metastatic disease would be in accordance with accepted standards of medical practice. The 
case records describe prior SBRT to the right adrenal gland, and imaging showing 2 new sites of disease. While 
the treatment planning records describe the plan to treat the spine, the 2/15/23 bone scan shows a lateral right 
orbital roof metastasis and a possible additional bone lesion of the right posterior pelvis. This is not described 
further. The patient appears to have been simulated for the pelvic lesion. The ASTRO model policy requires all 
sites being amenable to treatment with SBRT. The standard has generally to treat lesions synchronously. It 
would be unfavorable to treat one lesion and then later treat another lesion. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT).  
 
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 SPRINT peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve SPRINT PNS. You say that you disagree with the Plan's denial. 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 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 SPRINT PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral knee pain. The enrollee takes Mobic, Gabapentin and Tramadol for 
pain. The enrollee had a psychological P3 test performed. The enrollee is status post viscosupplementation and 
radiofrequency ablation of the genicular nerves. The use of Sprint is considered experimental/ investigational 
for knee pain. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SPRINT peripheral nerve stimulation (PNS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF offers treatment the enrollee needs. The Plan 
denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that the 
admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to be somewhat unstable and require additional acute care services 
that can safely be administered at the current facility until more stable and appropriate for transfer. You do not 
require services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a cardiac contractility modulation 
(CCM) system (0408T). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether implantation of the CCM system in this enrollee is medically necessary for the 
treatment of congestion heart failure which has been deemed refractory to optimal medical therapy. An 
exhaustive review of the current medical literature pertaining to the CCM system confirms multiple 
observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus 
control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM 
providing meaningful improvement in quality-of-life scores and objective functional capacity.   
While the clinical studies led to the Food and Drug Administration approval in 2019, CCM remains the subject 
of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. At the current time, the CCM system is not determined to be medically 
necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a cardiac contractility modulation (CCM) system (0408T).
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 hospital is trying to release you now and you are 
seeking appeal to save your life and get the physical wellbeing back on track and back to an active lifestyle. 
The Plan denied your request. The Plan says your records do not show that you have complex rehabilitation 
needs requiring you to be seen 3 times per week by a rehabilitation doctor for evaluation of your functional 
goals and progress, medically necessary care may be provided safely in a different level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported fixed denture (D6115) 
and implant/abutment supported interim fixed denture (D6118). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 30, 2020, and 
November 12, 2020. Therefore, we decided that the Plan does not have to pre-approve an implant/abutment 
supported fixed denture (D6115) and implant/abutment supported interim fixed denture (D6118).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GELSYN-3. 
 
You asked the Plan to pre-approve GELSYN-3. The Plan denied your request. The Plan says the enrollee has 
not met the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve GELSYN-3. Our reviewer says that 
GELSYN-3 is not medically reasonable and necessary in this case. Our physician reviewer found that there is 
no indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GELSYN-3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GELSYN-3.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on September 
29, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99285 is Emergency Department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 
complexity medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the emergency room services. Our reviewer says that the 
code billed is not supported by the records provided. Our reviewer found the medical decision making performed is more accurately described by code 99284. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on September 29, 2022.