Persius/hicric huggingface dataset:
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 enrollee exceeds criteria for an 
LTACH admission. The Plan denied your request. The Plan says the enrollee does not require any services that 
are not available to you in the current hospital. 
 
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 the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on August 29, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated) (eg, 
hereditary breast and ovarian cancer) gene analysis; known familial variant (81215). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee qualifies for the requested BRCA1 
testing. You also say that they have multiple family members with a history of breast cancer. The Plan denied 
your request. The Plan says the requested genetic testing is not covered for enrollees with no personal history 
of breast or ovarian cancers. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1 genetic testing of an unaffected 
Medicare eligible individual or family member is considered not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the file does not support that the enrollee has a 
personal history of breast or ovarian cancer. Therefore, we decided that the Plan does not have to pre-approve 
BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known 
familial variant (81215).
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 services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee can receive 
the care needed in another setting such as a skilled nursing facility, at home with home health services or in an 
outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided 
on July 12, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit 
when provided in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider an ambulatory surgical center to be a home.  
 
Records show that the pneumatic compression device and appliances was used in an ambulatory surgical 
center. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and 
appliances provided on July 12, 2022.
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 April 10, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says these services were not medically necessary. The Plan also says that prior 
authorization was not obtained. 
 
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 transportation via ambulance from the hospital to the 
nursing home was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van) without 
endangering the enrollees condition. Our reviewer also found that a prudent layperson would not believe that 
immediate medical attention was required for someone who was being discharged from the hospital.  
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 April 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty component for the prosthetic leg (L5999). 
 
You asked the Plan to pre-approve a heavy-duty component for the prosthetic leg. You say that the services are 
necessary. The Plan denied your request. The Plan says the heavy-duty component is unbundled and is 
included in an already approved item. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5999 (LOWER EXTREMITY 
PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used to bill for any features or functions 
included in the socket or addition codes. Use of L5999 is incorrect coding (unbundling). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty component for the prosthetic leg have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy-duty component for the prosthetic leg (L5999).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 26 occupational therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee's condition requires increased 
assessment, modification, and skills from a therapist to deliver a safe and appropriate treatment intensity, to 
facilitate safe progression of functional tasks. The Plan denied your request. The Plan says the enrollee's 
records do not have evidence of need for continued occupational therapy services beyond those which were 
approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee with hip fracture 3 months ago with dementia does not 
meet coverage criteria for the requested additional therapy visits. The documentation does not support the need 
for additional physical therapy visits which are not medically necessary for coverage. The additional visits are 
not medically necessary and are not reasonable, carry over with therapy with dementia is questionable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional 26 occupational therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lynparza. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lynparza.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0427, A0425) provided on August 
5, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transportation was medically necessary 
and was reported correctly. The Plan denied your request. The Plan says that this claim was not submitted with 
an appropriate primary diagnosis code to support medical necessity per the Local Coverage Article A54574. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states that the primary diagnosis code billed on this claim 
is M25.559. However, the Plan did not include a copy of the original claim as it was submitted by the provider. 
Without this document, we cannot verify the codes billed. In addition, the Plan argues that M25.559 is not an 
appropriate primary diagnosis code per the Centers for Medicare and Medicaid Services, Local Coverage 
Article - Billing and Coding: Ambulance Services (Ground Ambulance) (A54574). Although the Group One 
paragraph of this article lists many diagnosis codes which may be used as a primary diagnosis for ambulance 
claims, only one code is specifically listed as not supporting medical necessity (Z76.89). This means that just 
because M25.559 is not among the list of suggested codes, it is not explicitly not medically necessary either. 
The Plan's denial is not substantiated by documentation or by the citation used in this case. Therefore, we 
decided that the Plan has to pay for ambulance transportation services (A0427, A0425) provided on August 5, 
2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana. 
 
You asked the Plan to pre-approve Invokana. You say that the enrollee has tolerated the medication well. The 
Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana.  
 
 
 Benefits for Invokana may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 18, 2022, to 
January 24, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services/diagnoses were reported correctly and are supported as billed. The Plan denied your request. The Plan 
says the DRG submitted on this claim is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute kidney failure, unspecified (N17.9). We asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally 
billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer 
found that the enrollee with chronic kidney disease presented to the hospital with gross hematuria and 
creatinine (Cr) of 2.2. Throughout the hospital stay, repeated Cr measurements ranged between 1.8 and 2.2 
with a discharge level at 1.9. This strongly suggests that the enrollee was at or near their kidney function 
baseline. There was no clinically significant rise in Cr or other evidence from testing to suggest the enrollee 
had acute on chronic kidney failure to justify the diagnosis code acute kidney failure (N17.9); therefore, it was 
not sufficiently supported in the documentation.   
 
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 January 18, 2022, to January 24, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg 
(Q5103). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has been diagnosed with untreated 
Colitis. 
 The Plan denied your request. The Plan says that the records do not support that Infliximab is medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the record supports that enrollee is very ill indeed, and likely has fulminant colitis with sepsis. The 
enrollee has not responded to IV (intravenous) antibiotics and IV corticosteroids. The use of dose-optimized 
infliximab may be lifesaving for this enrollee, and as such is medically appropriate and necessary as soon as 
possible. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve the injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg (Q5103).  
 
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 power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you would like to do more activities like 
church but are unable to walk far with your walker. You would like to socialize more with other people your 
age. With a scooter, you would be able to go out more to places that require a lot of walking. The Plan denied 
your request. The Plan says your records from your doctor specifically state you can move about your home 
with your seated walker and the scooter is ordered to help with moving outside the home. Helping with 
mobility outside the home is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 
300 pounds (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 51785, 95861, and 95870, billed for February 28, 
2022. 
 
You asked the Plan to pay for codes 51785, 95861, and 95870. The Plan denied your request. The Plan says the 
billed codes are not supported. 
 
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 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 codes 51785, 95861, and 95870. Our reviewer says that the 
use of codes 51785, 95861, and 95870, is not supported by the records provided. Our reviewer found that for 
code 51785, the procedure report does not include enough documentation to confirm EMG of anal or urethral 
sphincter was performed.  Procedure report documents "Anal Sphincter Electromyography (EMG): Subdermal 
electrodes were placed in the anal sphincter to monitor electromyographic (EMG) responses during the 
procedure" The records do not document electrical activity measured with the bladder filled and during emptying. Therefore, this procedure cannot be verified. For code 95861, the procedure report does not include 
enough documentation to confirm this procedure has been performed.  The procedure report documents 
"SSEP's & Lower Extremities: Baseline somatosensory evoked potentials (SSEPs) were obtained post-
positioning and prior to incision.  Responses were acquired and digitally processed for immediate analysis.  
Bilateral upper and lower extremity SSEP components consisting of cortical and subcortical responses were 
acquired and easily reproduced.  The baseline waveforms were used as a template against which all 
subsequently gathered traces were judged for conformity of latency and amplitude".  In this case, the 
documentation does not describe needle EMG. As per codify, "an electromyograph is used to record electrical 
activity that skeletal muscle cells produce while the provider inserts needles into the muscle during rest and 
while contracted. The provider can hear the recordings on a loudspeaker". For code 95870, the procedure report 
does not include enough documentation to confirm procedure has been performed.  The procedure report 
documents "Transcranial Motor Evoked Patentials: Baseline transcranial motor evoked potentials were 
obtained post-positioning and prior to incision.  A compound muscle action transcranial stimulation of the 
primary motor cortex".  The procedure report does not describe needle insertion, with the muscle at rest and 
during contraction. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 51785, 95861, and 95870 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 51785, 95861, and 95870, billed for February 28, 2022.