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

We decided that the Plan does not have to pay and additional amount for the acute inpatient hospital care
provided from July 9, 2020, to July 18, 2020.
You asked the Plan to pay and additional amount for the inpatient care. You say that the secondary diagnosis is
supported. The Plan denied your request. The Plan says the secondary diagnosis code, G93.6, 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 secondary diagnosis code G93.6, defined as
Cerebral edema. 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 and additional amount for the
inpatient are. Our physician reviewer found that Cerebral edema was noted in the radiology report. Cerebral
edema (G93.6) was listed as a secondary diagnosis. The reviewer found there was no progress note or other
treating physician's documentation which diagnosed the enrollee as having cerebral edema putting all the
clinical information and imaging information together to list this diagnosis as a treated diagnosis associated
with this admission. Therefore, there is insufficient support made in the provided documentation that the G93.6
is an appropriate secondary diagnosis.
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
and additional amount for the acute inpatient hospital care provided from July 9, 2020, to July 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic panel testing provided on July 2, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because a single procedure
code should be billed for this panel testing.
The Plan must follow Medicare rules. Medicare rules say that multigene testing panels must be billed with a
single procedure code.
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we
decided that the Plan does not have to pay for genetic panel testing provided on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.
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 test at issue in this appeal, FISH testing, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on March 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 95822 (EEG recording in coma or sleep only) and 51785
(needle electromyography studies or anal or urethral sphincter). Code 95822 is a column II code with a
modifier indicator of 1 when billed with column I code 51785. Code 95822 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
electroencephalogram (EEG) rendered on March 9, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that Opdivo is not medically reasonable and necessary for
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been
met.
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 Opdivo. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-
year-old who has been diagnosed with stage IIIA non-small cell lung cancer. In this case, since the patient has
progressed on prior immunotherapy the request for Opdivo is not FDA-approved for the enrollee's diagnosis. In
addition, the use of Opdivo is not supported by one of the major drug compendia or by clinical research that
appears in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to
pre-approve Opdivo
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 14, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says records were not
provided to support the medical necessity of this testing.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The submitted documentation does not contain medical records from
the ordering provider. Without these records, it cannot be confirmed that Medicare coverage criteria have been
met. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided this
enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in
the home with home health services or in a long-term care facility on a part time basis appear appropriate in
this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that indications for panniculectomy are not met.
The Plan must follow Medicare rules. Medicare rules say that panniculectomy can be covered if the LCD criteria have been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The record does not indicate that the enrollee has intertrigo. A skin examination is noted to be normal without rash or lesion. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on February 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. We find that CPT code 75625 is not supported in the medical record. Specifically, there is no documentation of an abdominal aortography by serialography with radiological supervision and interpretation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 75710 (unilateral extremity angiography) and 37226 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37226. Code 75710 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the imaging services rendered on February 17, 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 an LTACH admission would give the
enrollee the best chance at regaining his strength through aggressive rehabilitation and daily care from a
multidisciplinary team. The Plan denied your request. The Plan says the guidelines for coverage of LTACH
care have not been met. The Plan says that the enrollee's needs can safely be met in the current hospital 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 there is no documentation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 4, 2021 by an out-of-
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 drug testing provided on May 4, 2021 by an
out-of-network (OON) provider.
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 are not allowed to get out of bed and start the
needed therapy. The Plan denied your request. The Plan says you have not been able to tolerate much therapy.
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 physician reviewer found
that you were admitted to the acute care hospital for coronavirus. Your medical problems are stable. You do
not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you have a
need for physical and/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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty services.
You asked the Plan to pre-approve kyphoplasty services. You say that this procedure is medically necessary for
your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that kyphoplasty services will be considered when there is
a fracture that is less than 12 weeks old and is documented by advanced imaging 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 kyphoplasty services. Our reviewer
says that the requested surgical services are not medically reasonable and necessary. Our physician reviewer
found the magnetic resonance imaging (MRI) scan does not show that the fracture is acute and less than 12
weeks old as required by the Medicare rules.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of kyphoplasty services have not been met. Therefore, we decided that the Plan
does not have to pre-approve kyphoplasty services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet (U-V) lens (V2755), a polycarbonate lens
(V2784) and anti-reflective coating (V2750) provided on August 3, 2021.
You asked the Plan to pay for a U-V lens, a polycarbonate lens and anti-reflective coating. You say that you
have photophobia, and the enhancements are needed for medical reasons. The Plan denied your request. The
Plan says the services at issue are not a covered benefit with your Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says you receive one set of lenses every calendar year which includes basic single
vision, lined bifocal, lined trifocal and lenticular lenses only. The Plan also says additional upgrades, extra
charges and/or any customizations are not covered such as tinting's, coatings and/or special lens materials.
We looked at the file and the Plan's rules. The EOC confirms that additional lens enhancements are not covered
under your Plan. Based on this information, we decided that the Plan's rules for coverage of a U-V lens, a
polycarbonate lens and anti-reflective coating have not been met. Therefore, we decided that the Plan does not
have to pay for an ultraviolet (U-V) lens (V2755), a polycarbonate lens (V2784) and anti-reflective coating
(V2750) provided on August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that the enrollee's complaints of pain showed up as weaknesses and tightness throughout his lower legs. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
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 the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition. 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 six (6) additional physical therapy (PT) visits.
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 do not have the means to get the type of care
needed to recover. The Plan denied your request. The Plan says you do not require an intensive,
multidisciplinary approach to daily therapy.
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 physician reviewer found
that you were admitted to the acute care hospital for respiratory failure, myocardial infarction, cardiogenic
shock and had coronary artery bypass grafting. Your medical problems are stable. The complexity of your
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: 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 LTACH care is medically necessary and
reasonable for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have
not been met.
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 there is no documentation 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.