Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on June 26, 2022 to July 
4, 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 this 
service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 records do not support the billed services. Our physician reviewer found standard criteria for sepsis was 
not met. DRG 871 is not supported.  
 
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 June 26, 2022 to July 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the patients nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Their medical and rehabilitation needs 
do require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says criteria for a continued SNF stay 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, there is no 
documentation that daily skilled services are required. Provided records do not document a significant decline 
in your functional status to necessitate daily inpatient skilled therapy services. You do not require daily skilled 
nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Records support that 
services in the home with home health care or in a long-term care facility on a part time basis are 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when the criteria 
listed in the Medicare Rules section is 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 manual wheelchair. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the evaluation of the enrollee's 
functional status did not include a gait evaluation. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need a power scooter for community use. 
The Plan denied your request. The Plan says that the requested power scooter is not covered when used outside 
the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia for diagnostic medial branch blocks. 
 
You asked the Plan to pre-approve general anesthesia for diagnostic medial branch blocks. You say that general 
anesthesia for diagnostic medial branch blocks is medically necessary. The Plan denied your request. The Plan 
says general anesthesia for diagnostic medial branch blocks is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not reasonable and 
necessary for facet joint interventions.  
 
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 general anesthesia for diagnostic medial 
branch blocks. Our reviewer says that general anesthesia for diagnostic medial branch blocks is not medically 
necessary. Our physician reviewer found that the medical record does not document any unique circumstances 
which would require pre-authorization of anesthesia for the approved procedure. The review has determined 
that the requested general anesthesia at issue in this case does not meet the Medicare LCD coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of general anesthesia for diagnostic medial branch blocks have not been met. 
Therefore, we decided that the Plan does not have to pre-approve general anesthesia for diagnostic medial 
branch blocks.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the urine lab panel provided from May 24, 2022, to June 29, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says that a panel must be 
billed as one unit of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that a panel must be billed as one unit of service. However, the 
Plan has not referenced a specific Medicare rule showing that the services were billed incorrectly. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the urine lab panel provided from May 24, 2022, to June 29, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth #'s 
3, 4, and 5 (D6240), and retainer crown - porcelain fused to high noble metal tooth #'s 2 and 6 (D6750). 
 
You asked the Plan to pre-approve codes D6240 tooth #'s 3, 4, and 5, and D6750 tooth #'s 2 and 6. You say that 
you feel pain when you eat and your gums get bruised. The Plan denied your request. The Plan says the dental 
services are not a medical necessity. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers codes D6240 
tooth #'s 3, 4, and 5, and D6750 tooth #'s 2 and 6 when the services are medically necessary and reasonable.  
 
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 codes D6240 tooth #'s 3, 4, and 5, and 
D6750 tooth #'s 2 and 6. Our reviewer says that the dental services are not medically necessary. Our physician 
reviewer found a fixed bridge may be considered for coverage when replacing a missing maxillary anterior 
tooth or two adjacent mandibular anterior teeth when no posterior teeth are missing. In this case, teeth #'s 3, 4 
and 5 are posterior teeth, therefore do not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of codes D6240 tooth #'s 3, 4, and 5, and D6750 tooth #'s 2 and 6 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble 
metal tooth #'s 3, 4, and 5 (D6240), and retainer crown - porcelain fused to high noble metal tooth #'s 2 and 6 
(D6750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission for the therapy you need. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical 
therapy and occupational therapy services, but the medical records provided do not clarify why you require an 
intensive inpatient rehabilitation therapy program. There is no support in the documentation that you require 
the intensive medical care and the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing facility level is 
not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the medical records do not include an arterial blood gas (ABG) study. There was a venous blood gas 
during the hospitalization on January 12, 2023, that showed a normal partial pressure of carbon dioxide in 
venous blood (PvCO2) value of 46. There are no pulmonary function tests demonstrating severe reduction in 
the forced vital capacity (FVC). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ForeseeHome monitoring program (0379T). 
 
You asked the Plan to pre-approve the ForeseeHome monitoring program. You say that the ForeseeHome 
monitoring program is medically necessary for patients at risk of vision loss from choroidal neovascularization. 
The Plan denied your request. The Plan says this at home monitoring service 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 the ForeseeHome monitoring program. 
Our physician reviewer found that the ForeseeHome monitoring program is not considered medically 
reasonable and necessary 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 the ForeseeHome monitoring program have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the ForeseeHome monitoring program (0379T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vitamin D sunlamp. 
 
You asked the Plan to pre-approve a sunlamp. You say that you have a vitamin D deficiency. You say that you 
do not tolerate supplements. You also say that a vitamin D sunlamp is medically necessary for you. The Plan 
denied your request. The Plan says there is no evidence-based reason the enrollee cannot take a vitamin D 
supplement. 
 
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 sunlamp. Our reviewer says that the 
requested vitamin D sunlamp is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no laboratory evidence that the enrollee suffers from vitamin D deficiency. There is no 
provider evidence that the enrollee develops hypoxia after taking vitamin D supplement. The enrollee is noted to be able to take multiple other medications, including a potassium supplement and medications for anxiety. 
Therefore, the reviewer found that the requested sunlamp is not medically necessary or reasonable. 
 
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 sunlamp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vitamin D sunlamp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on May 29, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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.  
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 service. Our reviewer found the documentation does not 
support the CPT code 99223. There is no indication that the decision making was of high complexity. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the initial hospital care (99223) provided on May 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultralightweight wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that please consider reversing the denial decision 
for this enrollee's request for a customized wheelchair. The Plan denied your request. The Plan says the 
requested service is not covered by Medicare or the Plan as the enrollee resides in a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the ultralightweight wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the conforming bandage (A6443) provided on August 17, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies were medically necessary for the enrollee. 
The Plan denied your request. The Plan says that there are no orders directed to the supplier. 
 
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. Specifically, the file shows that the physician who signed the order for the 
supplies in this case was under direct supervision of the attending physician. Therefore, we decided that the 
Plan has to pay for the conforming bandage (A6443) provided on August 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing identified with codes 80050, 87150, 
87798, and 87481 provided on November 22, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. The documentation shows that the laboratory services were 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 testing identified with codes 80050, 87150, 87798, and 87481 
provided on November 22, 2022.