Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services in the home for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements have not all been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services are not medically reasonable or necessary. Our physician reviewer found although the 
enrollee is at home and is ventilator dependent, he has been medically stable.  The ventilator is not new and the 
settings and management are stable. The management of a ventilator is considered skilled when the enrollee is 
newly discharged from the hospital or is having complications that can only be managed by a skilled 
professional under the direction of a physician. In this case, the enrollee is medically stable and requires 
custodial care. Although oversight by a skilled nurse is reasonable, 16 hours daily of private duty nursing 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 pre-approve private duty nursing services in the home for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20 mg tablet. 
 
You asked the Plan to pre-approve Xarelto. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Xarelto 20 mg tablet.  
 
Benefits for Xarelto 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on August 3, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that the eye refraction was required for your eyes as 
you have diabetes, and you had a significant change/deterioration in your eyes requiring this service. The Plan 
denied your request. The Plan says a medical refraction service (92015) is not covered by Medicare with the 
diagnosis submitted. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-
covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. 
Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis 
or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says additional PT is not medically necessary. 
 
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 additional PT visits. 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 that the additional requested therapy is not generally accepted as 
specific and effective therapy for your condition beyond what was approved by the health Plan. You have had 
prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. 
The requested services are not part of a maintenance program, are the specialized skill, knowledge and 
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional PT visits.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (73110) provided on June 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 73110 is 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. 
 
In this case, the CPT Code Manual definition of code 73110 is "Radiologic examination, wrist; complete, 
minimum of 3 views." 
 
 
 
 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 services. Our reviewer says that the use of code 73110 is 
not supported by the records provided. Our reviewer found that the medical records provided do not include 
sufficient documentation to validate that a "Radiologic examination, wrist; complete, minimum of 3 views" 
was the procedure that was performed on June 5, 2021. Therefore, this service cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (73110) provided on June 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0999) 
provided on April 15, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no 
payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 15, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0999) provided on April 15, 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 enrollee needs aggressive wound 
management and intensive physical therapy and occupational therapy due to weakness. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer 
to an LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 pre-approve an auricular peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request does not meet the definition of being reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit.  
 
The requested item is for auricular stimulation and is therefore not covered. Based on this information, we 
decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastrorrhaphy services coded 43840 and the omental flap 
services coded 49905 provided on October 23, 2019. 
 
You asked the Plan to pay for the gastrorrhaphy services coded 43840 and the omental flap services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not supported by the documentation. 
 
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 codes 43840 and 49905 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of a procedure note for gastrorrhaphy, suture of 
perforated duodenal or gastric ulcer, wound, or injury; therefore, code 43840 cannot be verified. The 
documentation submitted did not include documentation of a procedure note for omental flap, intra-abdominal; 
therefore, code 49905 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the gastrorrhaphy services coded 43840 and the omental flap services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gastrorrhaphy services coded 43840 and the 
omental flap services coded 49905 provided on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan 
provided on April 30, 2021. 
 
You asked the Plan to waive the coinsurance for a CT scan. You say that you already pay $180 in premiums 
and this service should be fully covered. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance, up to $75 per day, for diagnostic radiology services.  
 
You have been asked to pay $25.29, which is 20% of the allowed amount for a CT scan ($126.45 allowed 
amount x 20% coinsurance = $25.29). A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a computed 
tomography (CT) scan provided on April 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on June 2, 2021. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like this service reprocessed for 
payment. The Plan denied your request. The Plan says the claim has denied correctly in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests performed by the ASC other than 
those generally included in the facility's charge are not covered under Part B and are not to be billed as 
diagnostic tests. 
 
We looked at the file and Medicare rules. In this case, these diagnostic testing services are not among those that 
would generally be covered in the facility's charge. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ultrasound services provided on June 2, 2021.
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 you need SNF care. The Plan denied your request. 
The Plan says a lower level of care more appropriate. 
 
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 patient was admitted for surgical repair of a tib-fib fracture after a fall. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.  In conclusion, 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from November 10, 2020, to November 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis codes J96.21, J96.22, and G92. 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 use of diagnosis codes J96.21, J96.22, and G92 is not supported by the records provided. Our physician reviewer found that the enrollee was not in respiratory distress after treatment was initiated. Listed in the documentation were the diagnoses, J96.21 - Acute and chronic respiratory failure with hypoxia, J96.22 - Acute and chronic respiratory failure with hypercapnia, and G92 - Toxic encephalopathy. There insufficient evidence provided to support the above diagnoses as there was no objective hypoxia, hypercapnia or encephalopathy at the time of admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from November 10, 2020, to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) provided on March 25, 
2021. 
 
You asked the Plan to pay for the MAC services. The Plan denied your request. The Plan says this is not 
covered for the billed diagnosis. 
 
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 MAC services.  Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the anesthesiologist documented that the enrollee has an ASA physical 
status of 2 (ASA 2, which is used for a patient with a mild systemic disease). According to the American 
Society of Anesthesiologists (ASA), a monitored anesthesia care (MAC) is a planned procedure during which 
the patient undergoes local anesthesia together with sedation and analgesia. This enrollee does not have a 
diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of MAC. In this case, the 
patient has no significant PMH to warrant MAC for the upper endoscopy procedure. 
 
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 MAC services have not been met. Therefore, we decided that the Plan does 
not have to pay for the monitored anesthesia care (MAC) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on May 19, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 99140 is anesthesia complicated by emergency 
conditions (specify) (List separately in addition to code for primary anesthesia procedure). 
 
 
 We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status code of 
"B". A status code of B means that payment is always bundled into payment for other services not specified 
and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99140 provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a bupivicaine hydrochloride injection (S0020) provided on 
March 3, 2021. 
 
You asked the Plan to pay for a bupivicaine hydrochloride injection. You say that this is supported in the 
records. The Plan denied your request. The Plan says this is not a valid code. 
 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 S0020 is not supported in the medical record. Specifically, this code has a status 
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of a bupivicaine hydrochloride injection have not 
been met. Therefore, we decided that the Plan does not have to pay for a bupivicaine hydrochloride injection 
(S0020) provided on March 3, 2021.