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

 
We decided that the Plan does not have to pay for procedure code 33340 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim must 
be submitted to Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for services as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay for 
procedure code 33340 billed for date of service July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve phrenic nerve stimulator placement. 
 
You asked the Plan to pre-approve phrenic nerve stimulator placement. You say that the enrollee suffers from 
chronic fatigue, memory problems, and nighttime gasping. You say that the enrollee has tried continuous 
positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and supplemental oxygen with no 
relief. The Plan denied your request. The Plan says that the records do not show that the enrollee has chronic 
ventilator dependence. The Plan says that for complex sleep apnea, the evidence for placement of a phrenic 
nerve stimulator is insufficient, conflicting, or poor, and demonstrates an incomplete assessment of net benefit 
vs. harm. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 phrenic nerve stimulator placement. 
Our reviewer says that phrenic nerve stimulator placement is considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has predominantly central sleep apnea of moderate 
severity. He has persistent symptoms.  Positive airway pressure (PAP) titration was unsuccessful in adequately 
treating central events. There was no Cheyne-Stokes breathing. There is a diagnosis of ischemic 
cardiomyopathy with ejection fraction (EF) 40-45%, so adaptive-servo ventilation (ASV) therapy is 
contraindicated. Thus, treatment options are very limited for this enrollee.  Phrenic nerve stimulation has been 
shown to improve sleep quality and symptoms in patients with central sleep apnea (CSA), using a sham control 
design. The safety profile is reasonable, with persistence of benefits out to 5 years.  Although more study is 
needed to fully determine which enrollees benefit the most, the procedure is reasonable for this enrollee 
because of the lack of other options. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of phrenic nerve stimulator placement have been met. Therefore, we decided that 
the Plan has to pre-approve phrenic nerve stimulator placement.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be safely met by skilled 
nursing or home health. The Plan denied your request. The Plan says the denial of IRF services is correct. 
 
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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may need 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 this enrollee 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 an IRF admission and services.
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 need SNF services to become stable enough to 
take care of yourself. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for skilled nursing facility (SNF) care. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 19, 2021, 
to November 29, 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 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. 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 N17.0, defined as acute kidney failure with tubular 
necrosis. 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 documentation does not support the DRG billed. Our 
physician reviewer found the enrollee presented to the facility for a psychiatric evaluation. The enrollee was 
evaluated and admitted for alcohol intoxication and withdrawal. In this case, the enrollee's creatinine ranged 
from 1 to 1.3 during the hospitalization. There was no clinical or laboratory evidence of acute tubular necrosis. 
The documentation does not support diagnosis N17.0 (Acute kidney failure with tubular necrosis).  
 
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 November 19, 2021, to November 29, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous electrical nerve stimulation (TENS) 
device (E0730), provided on June 6, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this device is not covered for the documented diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that Neuromuscular Electrical Stimulation (NMES) 
to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, 
including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for 
the Transcutaneous electrical nerve stimulation (TENS) device (E0730), provided on June 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 97110. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526. 
 
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 97110 is a column II code to column I code 92526. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 97110 billed for date of service June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will improve with an 
LTACH admission. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
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. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that your provider has requested this 
specific osteogenesis stimulator. The Plan denied your request. The Plan says you must receive your care from 
a network provider. 
 
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 
an osteogenesis stimulator to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee needs a follow-up CT scan because 
the enrollee can have cancer. The Plan denied your request. The Plan says the CT scan is not medically 
necessary to repeat before 3 months which was also recommended by the enrollee's radiologist. 
 
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 the CT scan. Our reviewer says that the 
repeat chest CT scan after 2 months is not medically necessary. Our physician reviewer found that this enrollee 
has chronic obstructive pulmonary disease, bronchiectasis, and respiratory symptoms. The CT scan of the chest 
for purpose of lung cancer screening was done October 21, 2022. This showed some new tiny pulmonary 
nodules, new LLL atelectasis, as well as tree-in-bud areas. The LUNG-RADS score was 4a, with recommended 
follow-up CT scan in 3 months. The 3-month follow-up CT scan is reasonable and medically necessary. The 2 
months is too soon to expect to see nodule growth due to cancer. The 3 months is more appropriate, as long as 
the enrollee is stable or improving clinically. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the chest.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 7, 
2022, to April 12, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are appealing the denied SNF stay. The Plan denied 
your request. The Plan says there were no daily skilled needs; therefore, the SNF services were 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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 7, 2022, to April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced pneumatic compression pump and segmental 
pneumatic appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve advanced pneumatic compression pump and segmental pneumatic 
appliance. You say that you need the requested services. The Plan denied your request. The Plan says the 
service can be provided by an in-network provider. 
 
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 
advanced pneumatic compression pump and segmental pneumatic appliance to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88381 billed for date of service December 
14, 2021. 
 You asked the Plan to pay for procedure codes 88381. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88381. This means 
there is both a professional and technical component for the CPT codes. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT codes 88381. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88381 billed for date of service December 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791), and 
psychotherapy, 60 minutes with patient (90837), rendered on dates of service August 1, 2022, through 
September 7, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and psychotherapy. You say that the 
services should be covered. The Plan denied your request. The Plan says this service is not covered when done 
by this type of doctor or specialist. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
(90791), and psychotherapy, 60 minutes with patient (90837), rendered on dates of service August 1, 2022, 
through September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional crowns (D2740 x2). 
 
You asked the Plan to pre-approve the two additional crowns. You say that your teeth are breaking, and your 
bones are not strong. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted because the Plan has already agreed to pre-
approve two crowns (D2740 x2). Therefore, we decided that the Plan does not have to pre-approve two 
additional crowns (D2740 x2).