Persius/hicric huggingface dataset:
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 requires 25-30 days of 
pulmonary care in a LTACH setting. The Plan denied your request. The Plan says the request 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 2, 2022, 
through August 8, 2022, and billed with diagnosis codes A41.02 and G92.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.02 and secondary diagnosis G92.9 is supported by the records. The Plan denied your request. 
The Plan says the documentation submitted does not support primary diagnosis A41.02 and secondary 
diagnosis of G92.9. 
 
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 primary diagnosis code A41.02-Sepsis due to 
Methicillin resistant Staphylococcus and secondary diagnosis code G92.9-Unspecified toxic encephalopathy. 
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 primary diagnosis of A41.02-
Sepsis due to Methicillin resistant Staphylococcus and secondary diagnosis of G92.9-Unspecified toxic 
encephalopathy. Our physician reviewer found there was no other evidence of a systemic dysregulated 
response to a systemic infection to meet the Sepsis 3 criteria (2+ SOFA points). The member did not have 
evidence of a significant mental status change to suggest encephalopathy. Therefore, the diagnosis code, A41.9, 
sepsis from Methicillin-resistant Staphylococcus aureus (MRSA), is not sufficiently supported in the records, 
nor is the code, G92.9, toxic encephalopathy, sufficiently supported in the provided records.  
 
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 August 2, 2022, through August 8, 2022, and billed with diagnosis 
codes A41.02 and G92.9.
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 you need IRF services in order to return home 
independent. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and a consultation with a dermatologist to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and a consultation. You say that the enrollee has relocated to 
South Carolina. The enrollee has a history of skin cancers that have been removed in the past. She has noticed a 
rapid change in size with a concerning spot below her knees that rapidly appeared and fears it to be another 
skin cancer. The Plan denied your request. The Plan says the enrollee must use in-network providers to receive 
services/care. This service is available by a provider in your network. 
 
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 office visit and a consultation with a dermatologist to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. 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. 
 
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 Eylea. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 21, 2022, 
to September 27, 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 the enrollee is an 82-year-old male who was treated in the hospital for 
pneumonia and was treated with antibiotics. The provided documentation described the patient with normal 
creatinine, normal platelets, oriented x3, and mean arterial pressure greater than 70. Although there was 
respiratory dysfunction, it was directly related to the pneumonia. Bilirubin was 1.7, however, there was no 
other evidence of a systemic dysregulated response to a systemic infection to meet the Sepsis 3 criteria. 
Therefore, the diagnosis code, A41.9, sepsis, is not sufficiently supported in the records.  
 
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 September 21, 2022, to September 27, 2022, 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 an ultralightweight wheelchair (K0005) and related supplies 
provided on November 30, 2022. 
 
You asked the Plan to pay for an ultralightweight wheelchair and related supplies. You say that the items at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for an ultralightweight wheelchair (K0005) and related supplies 
provided on November 30, 2022.
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 medical needs could be met at a lower level. 
 
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 pay for the knee orthosis (L1843) and suspension sleeve (L2397) 
provided February 23, 2022. 
 
You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says under Medicare guidelines, this request is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the enrollee has not had recent surgery or a recent injury. The documentation does 
not support that the joint is unstable or that there is joint laxity. The requested knee orthosis 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1843) and suspension sleeve (L2397) provided February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged 
hospitalization and the intensive skilled service that are provided in the LTACH setting. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met in 
the current setting. 
 
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 in this case, the documentation does not support that the enrollee has a need for 
complex medical treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, 
complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that 
are not available at the acute care hospital or the skilled nursing facility. The requested treatments are not 
medically necessary at the LTACH level of care. The enrollee has improved medically and can receive further 
care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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 long term acute care hospital (LTACH) services.
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 you are requesting an expedited 
reconsideration stating the enrollee is stable to discharge to the LTACH and has too many medical issues that 
cannot be handled in a lower level of care. The Plan denied your request. The Plan says the requested LTACH 
services are not medically necessary, reasonable or appropriate for the diagnosis and condition of the enrollee 
at this time. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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 basivertebral nerve ablation using the Intracept 
Procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the provided documentation demonstrates the 
enrollee clearly meets the Food and Drug Administration indications for use. The Plan denied your request. 
The Plan says there is not enough clinical evidence to support the effectiveness of this procedure, and therefore, 
the requested service cannot be approved. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that the Intracept procedure targets the basi-vertebral nerve for the relief of chronic vertebrogenic low back pain.  Medicare guidelines consider this type of system unproven and not 
medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone 
use of the Intracept device to established surgical decompression are needed. Published studies do not 
demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard 
surgical treatment. The review has determined that the requested Intracept procedure 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve basivertebral nerve ablation using the Intracept Procedure (64628 and 64629).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on December 8,  2022. 
 
You asked the Plan to pay for the ambulance service. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet criteria 
for the ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service. Our reviewer says 
that the ambulance transport was not medically necessary.  Our physician reviewer found the transportation via ambulance from the hospital to the  enrollee's residence 
was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport.  Transportation could have been 
provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 
condition. 
 
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 ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport provided on 
December 8,  2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee clearly meets the established defining criteria for a medically appropriate 
LTACH admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee can receive further care at the current acute care hospital or a lower level of 
care when deemed appropriate. 
 
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 long term acute care hospital (LTACH) services.