Persius/hicric huggingface dataset:
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 you need rehabilitation following knee replacement 
surgery and that you have other medical care needs and problems with your mobility. The Plan denied your 
request. The Plan says the enrollee does not require the intensity of care and therapy of inpatient rehabilitation. 
Alternatives of Skilled Nursing Services at a skilled nursing facility, home health, or outpatient therapy were 
identified. The enrollee's knee surgeon recommended inpatient rehabilitation for 3 hours a day of PT and OT in 
order to decrease overall deficits in self-care and mobility in order for the enrollee to be able to return home to 
live independently. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for total knee replacement. 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 patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
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 IRF admission and services.
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 the enrollee will need 24 hour nursing for safety, 
patient/family education on medical and disease management, monitoring of vital signs, and medication 
administration. The Plan denied your request. The Plan says the enrollee doesn't meet the requirements and 
could receive care in another setting. We could review alternate settings if requested such as a skilled nursing 
facility, outpatient setting or home health 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 enrollee was admitted for a stroke and surgical repair of 
a hip fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you 
have a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on October 9, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test determines the probability for 
malignancy. The Plan denied your request. The Plan says the test is considered investigational. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that the enrollee received a Nodify lung nodule risk assessment testing. The test at issue in this 
appeal was requested for screening purposes. Screening services such as pre-symptomatic genetic tests and 
services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not 
covered. Therefore, we decided that the Plan does not have to pay for the testing services provided on October 
9, 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 the enrollee continues to have very low endurance 
and poor strength. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
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 enrollee was admitted for clostridium difficile colitis and acute renal failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 24, 
2022. 
  You asked the Plan to pay for the abdominal ultrasound (76705). You say that the patient had multiple exams 
on this date of service and the reports support the level of service. You say that the claim should be 
reconsidered for processing. The Plan denied your request. The Plan says CPT code 76705 was not billed with 
an allowed modifier and is considered bundled into the payment of 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 24, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the Colonoscopy, flexible; with biopsy (45380) provided on October 
23, 2021. 
 
You asked the Plan to pay for code 45380. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed without 
modifier 52. 
 
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 45380 is Colonoscopy, flexible; with biopsy, single or multiple. 
 
We find that CPT code 45380 is supported in the medical record. Specifically, the medical record does not 
indicate that the colonoscopy was partially reduced or eliminated. Modifier 52 would not be appropriate for 
billing in this case. The Plan has provided no other rationale for the denial of payment. Based on this 
information, we decided that Medicare rules for coverage of code 45380 have been met. Therefore, we decided 
that the Plan has to pay for the Colonoscopy, flexible; with biopsy (45380) provided on October 23, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 19, 2021, 
to February 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were reported 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 secondary diagnosis code J96.10, defined as acute 
respiratory failure with hypoxia. 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 
provided. Our physician reviewer found that acute respiratory failure with hypoxia is not sufficiently supported 
in the provided documentation. The enrollee presented with an aspiration episode and hypoxia requiring 
continuous positive airway pressure (CPAP), which was weaned upon arrival to the emergency department 
(ED). In the ED, she did not have respiratory distress, no longer was requiring CPAP, and oxygen requirements 
were quickly weaned down to low doses on the day of admission without hypoxia or distress. The enrollee did 
not have an abnormal pH (7.33). Therefore, the diagnosis is not supported in the records. 
 
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 
further pay for the inpatient hospital care provided from February 19, 2021, to February 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on October 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on June 23 to June 27, 2021, billed 
with DRG 070 and secondary diagnosis code I50.33. 
 
You asked the Plan to pay for inpatient care. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  
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 secondary diagnosis code I50.33, Acute on chronic 
diastolic (congestive) heart failure. We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient care. 
Our reviewer says that the services at issue do not meet criteria for payment as billed. Our physician reviewer 
found that the provided documentation did not describe the enrollee as in any respiratory distress or pulmonary 
embolism signs of fluid overload or other signs of acute congestive heart failure (CHF) beyond baseline. There 
is no documented diuretic use or other treatments for acute CHF. A chest X-ray did not reveal signs of acute 
CHF.  
 
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 care provided on June 23 to June 27, 2021, billed with DRG 070 and secondary diagnosis code 
I50.33.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (01630) provided on July 2, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. The Plan has not provided support for its denial rationale nor an explanation why 
an anesthetist would not be able to render the services at issue. It is the Plan's responsibility to substantiate its 
denial. In this case, the Plan has not substantiated its denial so we must find in your favor. Therefore, we 
decided that the Plan has to pay for anesthesia services (01630) provided on July 2, 2021.  
 
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 the CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered because the enrollee 
cannot do prandial insulin due to caring for their spouse. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee is being treated 
with three or more administrations per day of insulin and the documentation shows the insulin treatment 
regimen is not based on the blood glucose monitor (BGM) or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation of varicose veins 
(36475). 
 You asked the Plan to pre-approve the procedure. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the records do not support medical necessity 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. 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 varicose veins of the lower extremities. She reports redness on the legs, legs 
feeling heavy and tired, and occasionally she has leg cramps. Doppler suggested reflux, CEAP score was C3, 
and VCSS: 7. However, missing from the provided documentation was the size and reflux degree of the greater 
saphenous vein intended for treatment. Reflux of >500 msec is required to meet criteria. Therefore, without 
sufficient support made for this request, the radiofrequency ablation procedure will be considered not medically 
necessary at this time. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous radiofrequency ablation of varicose veins (36475).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are multiple plausible pathologic sources of significant pain generation. 
Documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasounds provided on January 17, 2022. 
 
You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the code exceeds the allowable unit of service. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the breast 
ultrasounds provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of nerve branches of knee using imaging 
guidance (64624) provided on January 12, 2022. 
 
You asked the Plan to pay for the destruction of nerve branches of knee using imaging guidance. You say that 
you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan 
says no valid diagnosis codes were billed to support payment for code 64624. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for Current Procedural Terminology 
(CPT) codes 64400, 64405, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 
64448, 64449, 64454 and 64624 is limited to specific diagnosis codes. 
 
We looked at the file and Medicare rules. In this case, CPT code 64624 was billed without an appropriate 
diagnosis code valid for coverage. Based on this information, we decided that Medicare rules for coverage of 
the destruction of nerve branches of knee using imaging guidance have not been met. Therefore, we decided 
that the Plan does not have to pay for the destruction of nerve branches of knee using imaging guidance 
(64624) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre Sensors. 
 
You asked the Plan to pre-approve Freestyle Libre Sensors. You say that your blood sugar goes below 70 and 
your provider feels it is necessary for you to have continuous blood glucose monitoring. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation provided indicates you do not use insulin to treat 
your diabetes. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre Sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 
Sensors.