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

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint open arthrodesis, including bone 
graft. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented SI joint 
instability, fracture, or lesion. The use of SI joint fusion for degenerative back pain is considered experimental 
in nature. The services are 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 sacroiliac (SI) joint open arthrodesis, including bone graft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 24, 2022, to 
April 26, 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 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found that there was insufficient evidence to support organ failure directly related to a 
dysregulated response to systemic infection as the enrollee had less than 2 sequential organ failure assessment 
(SOFA) points. Sepsis-3 criteria was not met. As such, the code, A41.9 (sepsis) is not supported for this 
admission based on the provided documentation.   
 
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 April 24, 2022, to April 26, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a pinched nerve in your neck and have no 
feeling in your right arm and hand. You say that you are right handed and are unable to write, drive , eat, cook, 
open doors, use your computer, send text messages or even pick up objects. You say that you need the use of 
your hand because you live alone and are unable to properly care for yourself. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation can be provided in a 
lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: 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 you need IRF services to enable you walk unassisted 
before returning home. The Plan denied your request. The Plan says you do not meet the requirements for 
approval of the requested IRF services.  
 
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. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. Medically necessary services can be 
provided in a lower level of care.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan concurrently with a CT scan of the head. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that this test is needed to confirm the AD 
diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the record indicates the enrollee 
might have AD. The record provided does not establish that the enrollee meets the diagnostic criteria of both 
AD and FTD. The elements of the coverage criteria are not satisfied. The requested service cannot be covered 
at this time. 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PET scan concurrently with a CT scan of the head.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve Trulance. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.  Benefits for Trulance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction device (E0849) provided on June 10, 
2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the durable medical equipment (DME) was not ordered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee has a musculoskeletal or neurologic impairment 
requiring traction equipment and the appropriate use of a home cervical traction device has been demonstrated 
to the enrollee and the enrollee tolerated the selected device. There is no evidence that the enrollee has a 
diagnosis of temporomandibular joint (TMJ) dysfunction and has received treatment for the TMJ condition; or 
that the enrollee has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin 
halter is unable to be utilized; or, that the treating practitioner orders and/or documents the medical necessity 
for greater than 20 pounds of cervical traction in the home 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a cervical traction device (E0849) provided on June 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on June 29, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was a medically necessary part of this 
enrollees procedure/treatment. The Plan denied your request. The Plan says this service is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure, unless billed with an 
appropriate modifier and supported in the medical record. The rules say that the use of local anesthesia is not 
separately billable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is an anesthetic agent which was 
provided incident to a primary procedure. The payment for this service is included in the payment for the 
primary procedure. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided 
on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 28, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on April 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they can tolerate the intensity of 
therapy services with their limitations by pain and endurance.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed, with any type side rails, 
with mattress E0260.  
 
You asked the Plan to pre-approve the hospital bed. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
requested semi-electric hospital bed.  
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. 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 chronic obstructive pulmonary disease (COPD) and heart failure. The NCD 
280.7 criteria has not been met as the enrollee does not require positioning unavailable with a standard bed nor 
does the enrollee require frequent or immediate change in position.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the semi-electric hospital bed, with any type side rails, with mattress E0260.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee requires oral surgery in order 
to eat properly and reduce the risk of further health complications. The Plan denied your request. The Plan says 
these services are not covered benefits under the enrollee's dental or medical plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of the enrollees teeth or the structures directly 
supporting the enrollees teeth. These are dental services that are not covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve oral surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87491) provided on June 27, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code is 
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 87491 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique". 
 
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 lab services. Our reviewer says that the use of code 
87491 is not supported by the records provided. Our reviewer found that the medical records provided do not 
include sufficient results to validate Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique was performed on June 27, 2023. Therefore, this service cannot be 
verified. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (87491) provided on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
rehabilitation stay. 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 enrollee does 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve angioplasty with placement of vascular stents for claudication 
(37225, 37227, 37228, 37231, 37224, 37229, 37230, 37226). 
 
You asked the Plan to pre-approve angioplasty with placement of vascular stents for claudication. You say that 
this procedure is medically necessary. The Plan denied your request. The Plan says that the results of an 
angiogram are needed to determine if stenting of your vessels is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 angioplasty with placement of vascular 
stents for claudication. Our reviewer says that you need this procedure. Our physician reviewer found that the 
documentation supports the medical necessity of the interventions in question. There is satisfactory 
documentation that you have significant peripheral artery disease in the affected extremity with associated rest 
pain. This constitutes a limb threatening condition and warrants angiography and possible intervention. It is 
reasonable to approve codes for angiography and provisional approval for intervention codes, the details of 
which will be determined at the time of angiography. It is not reasonable to insist that the angiogram be 
completed prior to decisions regarding intervention as that would subject you to a second procedure, a second 
arterial access, and the attendant risks. It is not possible to know ahead of time what intervention codes will be 
required. However, the ultimate coverage of these codes would depend on the satisfactory documentation in the 
operative note at the time of the angiogram and possible intervention. Thus, this procedure is considered 
medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angioplasty with placement of vascular stents for claudication have been met. 
Therefore, we decided that the Plan has to pre-approve angioplasty with placement of vascular stents for 
claudication (37225, 37227, 37228, 37231, 37224, 37229, 37230, 37226).  
 
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.