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

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 18, 2021, to 
July 26, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services 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 DRG 542. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that it was reported that the enrollee had lost 10% of their weight in the prior 4 months due to poor oral intake, 
refusing nutritional supplementation. It was estimated that their calorie intake was approximately 40% or the 
requirements. Based on the provided documentation describing the patient as losing more than 5% of body 
weight in past 6 months, eating an estimated less than 50% of required calories, and acutely ill due to fall with 
body mass index (BMI) lower than 18, she meets the criteria for severe protein malnutrition. However, as the 
documentation does not show that she was treated for such (refused oral supplementation, no enteral feeds 
given, etc. ) it is not appropriate to use this code. Therefore, this code, E43, was not sufficiently supported in 
the documentation. Therefore, the DRG 543 was appropriate.   
 
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 rendered from July 18, 2021, to July 26, 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 want to be able to walk and need rehab. You 
said that you are continuing to lose strength and you need to be able to assist your sick wife. The Plan denied 
your request. The Plan says you do not meet criteria for IRF 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness and a fall. Your medical problems are stable and you have no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder. 
 
You asked the Plan to pre-approve a MRI. You say that You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the patient does not meet criteria for a MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the patient is a 77-year-old man with 
chronic left shoulder pain. At the most recent encounter, no provocative maneuvers were done during the 
physical exam.. There is notation of normal muscle strength throughout with no red flags.  No physical therapy 
or other conservative management has occurred. Absent such conservative management and in the absence of a 
red flag, the medical necessity of the requested MRI of the left shoulder has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services 
 
You asked the Plan to pre-approve the physical therapy services. You say that the enrollee needs to continue 
with physical therapy for strengthening to improve right shoulder functional mobility and decrease overall 
symptoms. The Plan denied your request. The Plan says the enrollee does not meet the criteria outlined in the 
Medicare rules, because of reaching plateau in treatment, and has no medical need for a professionally 
supervised maintenance program 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration. The enrollee can transition to an independent home exercise 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 the physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services billed with code 73721-26-LT provided 
on September 30, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with modifier used. 
 
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 73721-26-LT is magnetic resonance imaging, any joint of 
lower extremity, without contrast material. 
 
We find that CPT code 73721-26-LT is not supported in the medical record. Specifically, you billed this code 
with secondary diagnosis code S76.011A, described as strain of muscle, fascia and tendon of right hip, initial 
encounter. This diagnosis code cannot be billed with code 73721-26-LT. Based on this information we decided 
that Medicare rules for coverage of radiology services provided. have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services billed with code 73721-26-LT provided on September 
30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure codes 76380 and 99153. You say that the claim was billed correctly 
and should be paid The Plan denied your request. The Plan says payment for code 76380 is bundled into 
payment for code 37243 and 76380. 
 
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 76380 
is a column II code to column I code 37243 and 76380. 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.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We also find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to 
the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan 
does not have to pay for procedure code 76380 billed for date of service July 21, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Zilretta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
intra-articular corticosteroids would likely be less effective, and/or would likely have adverse effects for you 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
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 member exceeds the criteria for an 
appropriate LTACH admission. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
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 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. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: 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 this is the best level of care due to the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's care can be 
provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 they are currently 
receiving 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 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 lower-extremity prosthetics to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve lower-extremity prosthetics. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lower-extremity prosthetics to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If this enrollee has chronic carbon dioxide (CO2) retention, may benefit from bilevel positive airway 
pressure (BiPAP) with Average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was 
being treated for spinal stenosis of the lumbar region with neurogenic claudication. She presented with lower 
back pain that is dull, aching, sharp, and shooting. The exam reveals an antalgic gait and station. Strength, 
sensation, and reflexes are intact. The treatment plan notes she did not receive relief from MILD procedure and 
would like to proceed with Vertiflex at this time. 
 
However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. Food and Drug Administration (FDA) indications include implantation of the 
Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom 
operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees 
of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis including the planned level 
of implantation at L4-5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, 
and have not been adequately addressed in the medical records. There is no documentation of the enrollees 
height, weight, or body mass index. There is no discussion of scoliosis of the lumbar spine with no 
documentation of the Cobb angle. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Vertiflex 
Superion interspinous spacer at L4-5, in this case, 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular stress test and myocardial perfusion 
imaging, tomographic (SPECT) provided on February 25, 2022. 
 
You asked the Plan to pay for the cardiovascular stress test and myocardial perfusion imaging, tomographic 
(SPECT). You say that these services have been covered in the past. The Plan denied your request. The Plan 
says when members access healthcare services outside the geographic area we serve, the claim for those 
services will be processed through the Inter-Plan Medicare Advantage Program. 
 
The Plan contract says when members access healthcare services outside the geographic area we serve, the 
claim for those services will be processed through the Inter-Plan Medicare Advantage Program. 
 
We looked at the file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of the cardiovascular stress test and myocardial perfusion imaging, tomographic (SPECT) have not 
been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular stress test and 
myocardial perfusion imaging, tomographic (SPECT) provided on February 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Mycophenolate tablet. 
 
You asked the Plan to pre-approve Mycophenolate. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The case record indicates that the requested drug is a self-administered immunosuppressive drug not being used for a Medicare-covered organ transplant. Therefore, the self-administered drug requested 
here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Mycophenolate tablet.  
 
Benefits for Mycophenolate 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 pre-approve proton beam treatment. 
 
You asked the Plan to pre-approve proton beam treatment. 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 proton beam treatment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found routine use of proton therapy for esophageal cancer would not be furnished in 
accordance with accepted standards 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 proton beam treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam treatment.