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

 
We decided that the Plan does not have to pay for procedure code 99221 billed on July 26, 2021. 
 
You asked the Plan to pay for procedure code 99221. The Plan denied your request. The Plan says payment for 
this code is bundled. 
 
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 99221 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99221 billed on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the CardioMEMS device would 
improve the enrollee's quality of life and result in fewer hospitalization for heart failure. The Plan denied your 
request. The Plan says the requested device has been determined to be of uncertain value at this time. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 
14, 2022 to May 31, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not 
require/receive any skilled level medical management, nursing, or therapy during the time under review.  
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 pay for the 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from May 14, 2022 to May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from May 26, 2021 to 
June 7, 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 DRG 
673 should remain based on the documentation, treatment, clinical evaluation, monitoring, and coding 
guidelines. The Plan denied your request. The Plan says the documentation was incomplete regarding a 
diagnosis of acute tubular necrosis (ATN). 
 
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 principal diagnosis code, N17.0, defined as Acute 
Kidney Injury with Acute Tubular Necrosis (ATN). 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 the medical records did not support the billing of Acute Kidney 
Injury with Acute Tubular Necrosis (ATN) with DRG 673.  
 
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 May 26, 2021 to June 7, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gel One injection (J7326). 
 
You asked the Plan to pre-approve a Gel One injection. You say that you have been dealing with your knee 
problem for a while. You also say that you have been to physical therapy, and have done everything you can, 
and your only other option is surgery. The Plan denied your request. The Plan says there is no clinical 
documentation that you have taken over-the-counter pain reliever for knee pain, or have tried physical therapy, 
home exercises, activity modification, or weight loss.  
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 a Gel One injection. Our reviewer says 
that you do not meet the criteria for coverage for a Gel One injection. Our physician reviewer found the 
requested medication is a new start. The provided records do not indicate that you have tried and failed the 
Plan's preferred step one alternative. Our reviewer also found that the record does not indicate that you have a 
contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. 
 
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 Gel One injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Gel One injection (J7326).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a CT of the thorax. You say that you believe the enrollee needs a CT of the 
chest included in order to adequately rule out conditions that may be causing the enrollee's unexplained weight 
loss. The Plan denied your request. The Plan says the provided documentation demonstrates that the enrollee is 
a non-smoker, without respiratory symptoms or signs. The Plan also says that the chest x-ray was reported as 
unremarkable, and the enrollee's unintentional weight loss can be attributed to their poorly controlled diabetes 
mellitus, and unsupervised low-calorie diet. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT of the thorax. Our reviewer says 
that the medical necessity of CT of the chest has not been established in the submitted records. Our physician 
reviewer found the enrollee's history shows evidence of dementia, poorly controlled diabetes. According to the 
history, the enrollee had a 50-pound unexplained weight loss in the past and no cause was found prior to this 
episode but no records are in the chart concerning that time period. Our reviewer found that the enrollee has 
had a GI referral but has refused a colonoscopy. The chest x-ray from July 27, 2022, was negative. Our 
physician reviewer also found that the enrollee is not a smoker, and a physical exam of the chest was negative 
as well as review of systems except for weight loss. 
 
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 CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71250).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcranial doppler study of the intracranial arteries; 
complete study (93886), transcranial doppler study of the intracranial arteries; vasoreactivity study (93890), 
and transcranial doppler study of the intracranial arteries; emboli detection without intravenous microbubble 
injection (93892). 
 
You asked the Plan to pre-approve the transcranial doppler studies. You say that it is necessary for these 
services to be approved. The Plan denied your request. The Plan says the requested testing is not medically 
necessary at this time. 
 
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 transcranial doppler studies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you suffered a concussion. There is nothing in the records to suggest the 
presence of a cerebrovascular disorder or significant stenosis/occlusion that would benefit from such testing. 
Our reviewer found that provision of the requested testing in the current clinical scenario is not otherwise 
consistent with the generally accepted standards of care or practice. Nor is it the most appropriate level of 
service/care that could be provided. Such testing would otherwise exceed your needs as any results would not 
impact ongoing care and management. Our physician reviewer also found that for these reasons the requested 
service is not medically 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 the transcranial doppler studies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transcranial doppler study of the intracranial arteries; complete study 
(93886), transcranial doppler study of the intracranial arteries; vasoreactivity study (93890), and transcranial 
doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection (93892).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried and failed Ibuprofen, 
corticosteroid injections, bracing physical therapy, and home exercise programs without symptom relief. The 
Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the 
requested viscosupplement 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 Euflexxa. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Euflexxa. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drug(s). Our reviewer also found that there is no 
indication that the Plan's 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on July 2, 2021. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the billed 
services 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. 
 
We find that payment for CPT code 97530 is not supported in the medical record. Specifically, it is 
inappropriate to bill this code for therapy services provided in the home setting. There is a more appropriate 
code to bill for the services provided. Based on this information, we decided that Medicare rules for coverage 
of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapy services (97530) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PNS is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
The request is for placement of the Sprint PNS for low back pain rather than for a specific nerve. There is 
insufficient evidence to support the use of the Sprint PNS for the low back pain. The services are therefore not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint peripheral nerve stimulation (PNS) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the enrollee has significant 
sacroiliac joint discomfort. You say that enrollee states that when he stands, it is quite uncomfortable and he 
can only stand for a few minutes. The Plan denied your request. The Plan says the requested sacroiliac joint 
injection does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that if previous diagnostic or therapeutic SI injections of 
an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not 
effectively relieved the pain, further injections would not be considered 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 sacroiliac joint injection. Our 
reviewer says that a sacroiliac joint injection is not medically necessary. Our physician reviewer found that the 
medical record clearly indicates the previous sacroiliac joint injection did not effectively relieve your pain. The 
requested injection 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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient mental health services provided from May 1, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the number of 
absence days submitted is greater than the number of days for the billed stay. 
 
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 the the number of absence days submitted is greater than 
the number of days for the billed stay. In this case, the Plans rationale does not apply as no absence days are 
noted during the billed period. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the inpatient mental health services provided from May 1, 
2022, to May 3, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you are in pain, have bad balance, and 
have issues walking. You say that this is the least invasive device and is approved by the Food and Drug 
Administration (FDA.) The Plan denied your request. The Plan says there is limited clinical evidence to 
support the use of the requested device. 
 
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 Vertiflex procedure. Our reviewer 
says that the Vertiflex procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, and 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on February 
1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was discharged from the hospital to 
a nursing facility. The Plan denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code A0425 is ground mileage, per statute mile. We find that 
CPT code A0425 was billed with 339 units. This exceeds the medically unlikely edits for this code. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the ambulance transportation services provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 4, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is consistent with the standard of 
care practice guidelines. The Plan denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the testing services were not billed with a modifier suitable for payment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261). 
 
You asked the Plan to pre-approve a CT colonography. You say that your doctor recommended the 
colonography because a growth was found. The Plan denied your request. The Plan says the denial of CT 
colonography was appropriate given the clinical scenario presented. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT colonography. Our reviewer says 
that a CT colonography is not reasonable and necessary. Our physician reviewer found you have a history of 
rectal bleeding. Our reviewer found that you said you had a direct colonoscopy on June 22, 2022, but there is 
no report. Our reviewer also found that the records are very sparse, and the medical necessity of the requested 
CT colonoscopy is not described by the requesting physician. 
 
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 CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic (CT) colonography (74261).