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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex needs that 
cannot be managed at the skilled nursing facility at this time. The treating physician states the enrollee will 
require another 3 to 4 weeks to continue the transition from her acute illness. The Plan denied your request. The 
Plan says authorization denied because LTACH is not medically necessary, and the enrollee's needs can be met 
at 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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous process spine spacer device. 
 
You asked the Plan to pre-approve an interspinous process spine spacer device. 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 interspinous process spine spacer 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process spacer devices are experimental. 
More research is needed. 
 
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 interspinous process spine spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an interspinous process spine spacer device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplements device. 
 
  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 Hyalgan. Our reviewer says that 
Hyalgan (J7321) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. Our reviewer 
found that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that 
there is no documentation provided indicating that the Plans required drug(s) would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
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 require an intensive team to include 
a rehabilitation nursing staff, social worker and therapist to include physical and occupational therapy. The 
Plan denied your request. The Plan says authorization denied because IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic 
medical conditions. There are no rehabilitation nursing needs identified or documented in the record. At the 
current functional level, the enrollee with uncomplicated hip fracture does not need IRF level of therapies, and 
their rehabilitation needs can be met in lower setting such as in an 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 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: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that it is urgent that you receive 
this inpatient hospitalization. The Plan denied your request. The Plan says that your request is not medically 
necessary because your records show you do not have any mention of fainting or persistently fast heartbeat 
despite adequate treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record shows that the admitting physician reasonably expects that your necessary 
hospital care will span two midnights. 
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital admission.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our physician 
reviewer found based on the medical records provided the enrollee does not appear to be medically stable for 
discharge to skilled nursing due to his acute change in status on April 26, 2022; further work-up is reportedly 
underway.  
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 meets the Medicare criteria for IRF 
under the qualifying CMS-113 diagnosis of stroke and neurological conditions. The representative states the 
enrollee has tried and failed SNF level of care and requires IRF. The Plan denied your request. The Plan says 
authorization because IRF is not medically necessary. 
 
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 is medically stable and does not need close physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. At the current 
functional and inability to tolerate therapies, the enrollee does not need IRF level of therapies, and their 
rehabilitation needs can be met in lower setting such as in an SNF with intermittent therapies. 
 
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 mitral valve replacement surgery. 
 
You asked the Plan to pre-approve mitral valve replacement surgery. 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 mitral valve replacement surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation would not suggest that the mitral valve disease is of 
sufficient severity, as yet, to warrant valve replacement. As a result, at this time mitral valve replacement 
would not be considered medically reasonable and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mitral valve replacement surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve mitral valve replacement surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) to a urologist's office. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation and ground mileage. You say that 
you had a serious infection and right now your legs are paralyzed, and you cannot move, you are using a 
wheelchair. You also say that this transportation is for a follow up visit, because the doctor needs to know what 
the best way would be to continue to treat you and for you not to go into an infection again. The Plan denied 
your request. The Plan says ambulance transportation to a provider's office is not covered by Medicare or the 
health plan. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the elements of the coverage criteria are not 
satisfied, and the requested service cannot be recommended. Our physician reviewer found the record indicates 
that you require transportation to and from a urologists office. Our reviewer found that you are quadriplegic 
and require stretcher transportation. Our physician reviewer also found that the record does not indicate that 
your clinical condition is such that other methods of transportation, such as stretcher van, are contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance 
transportation (A0428) and ground mileage (A0425) to a urologist's office.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angiogram of arteries in the legs. 
 
You asked the Plan to pre-approve vascular surgery services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage 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 vascular surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Coverage criteria have not been met and the documentation does not support the 
procedures in question. The incomplete pulse examination only notes that dorsalis pedis and posterior tibial 
pulses are 1+. Ankle brachial index (ABIs) have been essentially unchanged at yearly intervals since 2016.  
Most recent ABIs are 1.4 bilaterally without documentation of toe pressures. The patient complains of fatigue 
and aching leg pain, worse on the left and the patient has documented spinal stenosis. There is a mention of the 
need for percutaneous transluminal angioplasty on the right (in addition to the requested procedure) even though the requested angiogram has not even been performed. Coverage criteria have not been met and there is 
insufficient support of the medical necessity of the procedure in the documentation to override health plan 
determination.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular surgery services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve angiogram of arteries in the legs.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second interpretation of the chest x-ray provided on 
September 14, 2021, billed with code 71046-26. 
 
You asked the Plan to pay for the second chest x-ray interpretation. You say that this was denied in error. The 
Plan denied your request. The Plan says this is a noncovered screening test. 
 
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 71046 is radiologic examination, chest; 2 views. 
 
 
 
 We find that CPT code 71046 is not supported in the medical record. Specifically, payment was already made 
by the Plan for a claim reporting code 71046-26-76. Modifier -76 denotes a repeat procedure or service by the 
same physician. However, the records provided show a duplicate of the same imaging report, both comparing 
to a prior x-ray done on September 10, 2021. There is no evidence that a second x-ray was performed or that a 
second interpretation of the image was performed. Based on this information, we decided that Medicare rules 
for coverage of the second chest x-ray interpretation have not been met. Therefore, we decided that the Plan 
does not have to pay for the second interpretation of the chest x-ray provided on September 14, 2021, billed 
with code 71046-26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical preparation of recipient site (15002 and 15003) 
provided on August 30, 2021. 
 
You asked the Plan to pay for surgical preparation of recipient site (15002 and 15003). You say that there are 
no bundling issues on CPT codes 15002 and 15003. The Plan denied your request. The Plan says procedure 
codes 19364 and 19371 were approved. The Plan also says that procedure codes 15002 and 15003 are not 
supported by the medical records submitted. 
 
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 15002 and 15003 is surgical preparation or creation of 
recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional 
release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The 
CPT Code Manual definition of code 15003 is surgical preparation or creation of recipient site by excision of 
open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and 
children (List separately in addition to code for primary procedure). 
 
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 surgical preparation of recipient site (15002 and 15003). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report describes skin flaps, which would not be reported with surgical 
preparation or creation procedure codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical preparation of recipient site (15002 and 15003) have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical preparation of recipient site (15002 and 
15003) provided on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 13, 2021, to 
March 14, 2021, as billed with diagnosis related group (DRG) 854. 
 
 
 You asked the Plan to pay for inpatient care billed with DRG 854. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 854 is not 
supported as the principal diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. The Plan argues that DRG 660 is more appropriate in this case, and the diagnosis of calculus of kidney 
and ureter (N20.1) should be re-sequenced as the principal diagnosis. 
 
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. 
 
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 billed with DRG 854. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
Our physician reviewer found that the enrollee presented to the facility with the chief complaint of abdominal 
pain. The correspondence described the symptoms of systemic inflammatory response syndrome (SIRS) as 
supported by the initial heart rate of 124, respiratory rate of 20, temperature of 98 and white blood cell count of 
12.5; however, these may be considered an appropriate response to infection and may not be clear evidence of 
a systemic infection in the absence of other indicators. History and physical documentation noted the enrollee 
presented with abdominal pain; however, the enrollee was also described to be in no acute distress, oriented 
and was described as "chronically ill", with a normal cardiovascular and peripheral perfusion exam. The 
enrollee was noted to have ureteral calculus, and acute renal failure with a component of obstructive uropathy. 
While the provider stated the patient had had "mental status changes" prior to admission, the Glasgow coma 
scale score was 15 both per emergency services and at presentation to the facility, and the providers physical 
examinations did not support the enrollee to be anything but oriented and alert. The review has determined that 
the medical records did not support the billing of principal diagnosis sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 854 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from March 13, 2021, to March 14, 2021, 
as billed with diagnosis related group (DRG) 854.