Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from April 28, 2021 to 
April 30, 2021, 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 the 
secondary diagnosis code, N17.9, for acute kidney failure is supported by the physicians' documentation and 
the information contained in the enrollee's medical record. The Plan denied your request. The Plan says the 
criterion was not 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, N17.9, defined as acute 
kidney 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found there was no clinical or laboratory evidence of acute kidney injury/failure. The 
review has determined that the medical records did not support the billing of acute kidney failure (N17.9). Our 
reviewer also found that the medical records support the billing of the revised DRG 066.  
 
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 from April 28, 2021 to April 30, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee is non-ambulatory. You also say that the enrollee requires a wheelchair with power tilt and recline. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options. The Plan says that the upgraded electronics are not medically necessary to control the three requested 
power options through the joystick. The Plan also says a seat lift does not serve a medical purpose and is not 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee does not have skin breakdown and is not at high risk as the enrollee has been non ambulatory for 
months without skin breakdown. The reviewer found that the enrollee does not have spasticity or use a catheter. 
The reviewer also found the enrollee has adequate upper body strength to manage multiple power switches. 
Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple power options is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the Prostate. 
 
You asked the Plan to pre-approve the requested waterjet ablation. You say that the enrollee would benefit 
from this treatment. The Plan denied your request. The Plan says the enrollee does not meet the age criterion 
for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that Transurethral Waterjet Ablation of the Prostate is 
covered for enrollees who are 80 years old or younger. 
 
We looked at the file and Medicare rules. The file shows that the enrollee is 81 years of age. Based on this 
information, we decided that Medicare rules for coverage of the requested waterjet ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the 
Prostate.
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 were completely independent prior to back 
surgery and ready to start extensive therapy at a acute rehabilitation facility. The Plan denied your request. The 
Plan says your records do not show that your rehab needs are complex, services you need can be provided 
safely in other settings, a skilled nursing facility, home with home health services or home with outpatient 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility, medically necessary care may be provided safely in a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from March 9, 2022, to  
March 29, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this type of provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor and a Marriage 
Family Therapist is not eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor and a 
Marriage Family Therapist. Medicare says that a Mental Health Counselor and a Marriage Family Therapist is 
not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay 
for psychotherapy provided from March 9, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that the enrollee needs a bilateral RFA to treat arthritis pain. 
You say that the enrollee received a transforaminal epidural steroid injection previously on February 23, 2023. 
The Plan denied your request. The Plan says since it has been more than two years since the last RFA 
procedure, it is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria.  
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 RFA. Our reviewer says that the 
requested RFA procedure is not medically necessary. Our physician reviewer found the provided 
documentation does not show that there is physical exam evidence of facet joint pain. The reviewer found that 
the cause of the enrollee's back pain remains unclear. Therefore, the reviewer found that the requested 
procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided from March 14, 2022, 
to March 16, 2022. 
 
You asked the Plan to pay for the services. 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. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit". The CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 99223 
and 99233 is not supported by the records provided. Our reviewer found that for code 99223, the 
documentation available for review does not support the encounter required decision making of high 
complexity. For code 99233, the documentation available for review does not support the encounter developed 
a significant complication or that medical decision making of high complexity was needed. 
 
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 (99223, 99233) provided from March 14, 2022, to March 16, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from July 7, 2022, to August 1, 2022. 
 
You asked the Plan to pay for home health services. You say that the home health services at issue have been 
billed correctly. 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 rules also say that a Notice of Admission (NOA) is a one-time submission to establish that the 
enrollee is under a home health period of care. 
 
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's denial states that payment for the home health period of 
care at issue is denied because the NOA was submitted untimely. However, the Plan has also attested that the 
NOA was submitted untimely relative to a prior period of care. The late submission does not affect payment for 
subsequent periods of care, such as the period at issue. The Plan has not provided any alternative rationales for 
denial. It is the Plan's responsibility to support its denial. In this case, the denial has not been supported, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for home health services provided from 
July 7, 2022, to August 1, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the criteria for approval have 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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that patient is still requiring frequent skilled 
nursing care/assessment and evaluating therapists recommend continued skilled therapy in current SNF. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Favorable

 
We decided that the Plan has to pay for the hospital discharge day management (99239) provided on August 2, 
2022. 
 
You asked the Plan to pay for the hospital discharge day management. You say that date of service August 1, 
2022, was a corrected claim, and the Plan has already recovered the discharge billed in error for that date of 
service. You also say that there is no longer any discharge on August 1, 2022, and you would like this claim to 
be reprocessed for August 2, 2022, as the correct discharge. The Plan denied your request. The Plan says that 
only one hospital discharge day management service is payable per patient per hospital stay. The Plan also says 
this denial is upheld as duplicate billing. 
 
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 record shows that you sent in a corrected claim, and you say the Plan took 
back the payment for August 1, 2022. However, the Plan has not provided any argument to disprove this. You 
also say that the Explanation of Benefits would prove your point, but this has not been provided by the Plan. 
Therefore, we decided that the Plan has to pay for the hospital discharge day management (99239) provided on 
August 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on January 12, 2022. 
 
You asked the Plan to pay for injections. 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 injections provided on 
January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 1, 2022, to 
January 3, 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 and diagnoses are supported as billed. The Plan denied your request. The Plan says the DRG submitted 
on this claim is not supported by the medical records provided. 
 
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 sepsis, unspecified organism (A41.9). 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 current criteria for reporting sepsis are not met. Systemic inflammatory response syndrome (SIRS) has been 
clinically invalidated as a definition of sepsis. A person with oxygen dependent chronic obstructive pulmonary 
disease (COPD) and an infection is very likely to become hypoxic. In such a setting, hypoxia would not be a 
marker for sepsis. Granted, there are few studies, but a Sequential Organ Failure Assessment (SOFA) score of 
4 has been a better criterion for sepsis in setting of pneumonia, consistent with the clinical observation of 
expected hypoxia in setting of pneumonia and COPD. The Plan has coded correctly as sepsis criteria not met.  
 
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 1, 2022, to January 3, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable pulse generator (IPG) 
system. 
 
You asked the Plan to pre-approve an Optimizer Smart IPG system. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Optimizer Smart IPG system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the proposed device and procedure is currently considered investigational 
and not recommended in any of the professional and scientific related societies as a part of heart failure management 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 Optimizer Smart IPG system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Optimizer Smart Implantable pulse generator (IPG) system.