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

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on July 17, 2022, to 
July 20, 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 the 
appropriate diagnosis was billed. The Plan denied your request. The Plan says the documentation does not 
validate the 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.   
 
In this case, you billed the inpatient services with diagnosis code I50.33, defined as acute on chronic diastolic 
congestive heart failure. 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 physician reviewer found that the enrollee presented to the 
hospital with abdominal pain, nausea, vomiting, and dizziness. Shortness of breath and chest pain were denied. 
The cardiovascular exam and pulmonary exam were normal. The chest x-ray showed no pulmonary venous 
congestion. The assessment was uncontrolled diabetes with borderline diabetic ketoacidosis (DKA). 
Intravenous insulin and hydration were administered. The progress note dated July 19, 2022, documents 
tachypnea. The heart and respiratory exams were unremarkable. An echocardiogram demonstrated normal left 
ventricle size, with a left ventricular ejection fraction of 65-70%, suggestive of stage II, diastolic dysfunction. 
The clinical documentation is insufficient to support the diagnosis code, I50.33.  
 
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 the inpatient hospital services provided on July 17, 2022, to July 20, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires dialysis and gets exhausted 
quickly. You also say the enrollee needs physician assessment more than three times a week and needs physical 
therapy and occupational therapy regarding walking. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in an IRF.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 have a need for physical 
therapy 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 
the 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on teeth # 28, and #30. 
 
You asked the Plan to pre-approve dental implants. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the examination showed no enlarged or tender masses in the 
submandibular or superior/anterior cervical regions. No peri-oral lesions and the TMJ is within normal limits. 
There is no lesion noted on the intraoral area. The maxilla is edentulous and the mandible has only 3 remaining 
teeth with a long-span fixed bridge from #22-27. The lower right posterior has sufficient inter-occlusal space. 
Site #18 Appears intact, Site #22 showed loss of mesial root. Site # 27 appears intact, and the bridge is solid. 
As per Dr. Wassel, there is an unknown amount of bone present in the right posterior mandible. There is most 
likely sufficient bone available to place two implants in #28, 30 sites for an implant-supported bridge. 
Unknown long-term prognosis of tooth #22 and therefore the bridge to #27. The member is aware that the 
bridge may fail sooner than later. It may be possible in the future to utilize the two implants on the left side to form a fixed lower prosthesis if the other teeth fail. The member refused the option of removable partial 
dentures. She stated she may only want one implant with one crown in the right posterior mandible. 
 
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 dental 
implants 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 dental implants. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found a review of the documentation indicates 
that although the current bridge in the mandible appears solid, the prognosis for retention is guarded and may 
fail. The service requested does not appear to address the long-term prognosis of restoring the mandible. Also, 
due to the inadequate radiographs a more detailed review of the mandibular structures was not possible. 
 
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 dental implants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental implants on teeth # 28, and #30.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR). 
 
You asked the Plan to pre-approve TAVR. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that TAVR may only be covered under certain 
circumstances. 
 
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 TAVR. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found the most recent 
echocardiogram showed aortic stenosis but is not consistent with severe stenosis. Guidelines would not support 
aortic valve replacement based on the submitted medical records. As a result, at this time the requested TAVR 
would not be considered medically necessary in the enrollee's 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 TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter aortic valve replacement (TAVR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee requires this ventilator to be able to 
perform standard activities of daily living. The Plan denied your request. The Plan says this is not the standard 
of care for the enrollee's condition. The Plan also says they have agreed to cover the ventilator for a 3-month 
grace period to work with providers to get the enrollee the appropriate equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for urinary tract infection, sepsis, and chest pain. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 07, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on October 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service December 
23, 2022. 
 You asked the Plan to pay for procedure code 76775. You say that this service was coded correctly. The Plan 
denied your request. The Plan says payment for code 76775 is bundled into payment for code 93975. 
 
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 76775 
is a column II code to column I code 93975. 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 76775 billed for date of service December 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you disagree with the denial 
and are requesting reconsideration. The Plan denied your request. The Plan says genicular RFA for the 
treatment of knee pain is considered experimental, investigational, and/ or unproven. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has osteoarthritis of the right knee. His past medical history is 
notable for GERD, history of DVT and PE on long-term anticoagulation, CKD stage III, asthma, HTN, and 
chronic respiratory failure presenting with lower extremity pain. He has been unsuccessfully treated with 
medication management and right genicular nerve ablations on April 14, 2021, January 5, 2022, and August 31, 
2022. This procedure is the subject of ongoing clinical trials and is therefore, considered experimental. The 
request is deemed not medically reasonable and 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including 
imaging guidance, when performed (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6219 billed for date of service January 18, 
2023. 
 
You asked the Plan to pay for procedure code A6219. You say that the code is for in-office dispensed items. 
The Plan denied your request. The Plan says procedure code A6219 is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6219 is not separately payable. 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 procedure code 
A6219 billed for date of service January 18, 2023.
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 continues to suffer ongoing 
medical complications and needs close daily physician monitoring which cannot be managed at a lower level of 
care. The Plan denied your request. The Plan says admission to the LTACH 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 have a need for physical 
therapy 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 
the 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulsed/coolief radiofrequency ablation (RFA) (64635, 
64636). 
 
You asked the Plan to pre-approve pulsed/coolief RFA. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are 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 pulsed/coolief RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found pulsed cool relief RFA is experimental at this time. 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 pulsed/coolief RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pulsed/coolief radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 10, 2022, to 
April 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 10, 2022, to April 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 remains 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. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case 
do not document an evaluation and management visit dated 05/09/2022 which includes a chief complaint, an 
extended history of present illness, a review of all additional body systems and a complete past, family and 
social history or an examination showing a general multisystem examination or a complete examination of a 
single organ system or medical decision making of high complexity showing 2 out of 3 of an extensive number 
of diagnoses or management options, an extensive amount and complexity of data reviewed and high risk of 
complication. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on May 9, 2022.