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

 
We decided that the Plan has to pay for the inpatient hospital services provided on October 14, 2022, to 
October 19, 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. The Plan denied your 
request. The Plan says that the billed DRG is not supported. 
 
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 diagnosis code A41.59. 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 use of diagnosis code A41.59 is supported by the records provided. Our physician 
reviewer found that the enrollee had documented systemic inflammatory response syndrome with culture 
positive for klebsiella. As such, diagnosis code A41.59 is appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on October 14, 2022, to October 19, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional skilled nursing visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that the enrollee cannot walk. You also say 
that the enrollee's doctor is monitoring their blood every two weeks. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
documentation does not indicate any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
The documentation indicates the enrollee has lower extremity venous ulcers and requires wound care, but 
records are insufficient to clarify that the wounds require the skills of a licensed/registered nurse for adequate 
care. No medical notes from the enrollee's treating physician are provided documenting an order or need for 
additional skilled nursing services. Records do not document the need for intravenous medications, new tube 
feeding or ostomy care or complex wound care. Therefore, the reviewer found that the the requested home 
health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 additional skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed with code A4595 for 
September 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid refill order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the supplies refill. 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 pay for the electrical stimulator supplies billed with code A4595 for 
September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound with a tertiary level provider. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services asked for do not need a higher level of care. 
 
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 enrollee is already scheduled for a diagnostic abdominal ultrasound at an in-network provider. 
There is no valid reason the approved ultrasound cannot be done at the in-network provider.  The images can 
be viewed electronically by providers. Medical necessity of the out of network imaging request has not been 
established in the submitted records.  
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 an ultrasound with a tertiary level provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on December 1, 2022, billed with 
procedure codes 97110, 97112, 97140, and 97530. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the billed codes are subject to a coding edit 
and cannot be reported together without a valid modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan is applying a coding edit that was deleted as of January 1, 1996. As there is no active edit for the 
billed codes, the Plan's denial of payment on this basis is not substantiated. Therefore, we decided that the Plan 
has to pay for practitioner services provided on December 1, 2022, billed with procedure codes 97110, 97112, 
97140, and 97530.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivare procedure. 
 
You asked the Plan to pre-approve Vivare procedure. You say that there is evidence that this service is a useful 
treatment and decidedly not experimental. The Plan denied your request. The Plan says this procedure is 
considered experimental and investigational. 
 
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 Vivare procedure. Our reviewer says 
that the requested Vivare procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found persistent clinical benefit from this procedure is insufficiently supported in the 
medical literature. Therefore, the reviewer found that the requested Vivare 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 Vivare procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vivare procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that a fast appeal is being requested for the denial of a 
SNF admission. You say discharge home at this time is unsafe due to the enrollee's current functional status, 
impulsivity, high fall risk and absence of family support. The Plan denied your request. The Plan says the SNF 
services requested do not meet the requirements for approval.  
 
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 the enrollee has stabilized medically and has been receiving skilled rehabilitation 
services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehabilitation services 
and continues to improve with daily skilled nursing and/or skilled therapy services. The enrollee could benefit 
from continued services at the current level of care. The enrollee has made slow progress with therapy, and 
there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive 
skilled rehabilitation services at the current IRF or be stepped down to a lower level of care when appropriate. 
There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled 
rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting 
have not been met. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 pay for the imaging services provided on January 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the imaging services provided on January 11, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the therapy services provided on March 17, 2023. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says that the claim 
was billed with a missing or invalid place of therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was billed with a missing or invalid place of 
therapy. However, the physical therapy services were provided by a physical therapist as part of a pre-op for a 
knee replacement. The records clearly show that therapy services were provided in an ambulatory surgical 
center (POS 24). The Plan has not provided documentation supporting its denial in this case. Therefore, we 
decided that the Plan has to pay for the therapy services provided on March 17, 2023.  
 
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 inpatient behavioral health treatment. 
 
You asked the Plan to pre-approve inpatient behavioral health treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of August 11, 2023, forward and could have been treated 
in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression. He was being cooperative and 
compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health treatment.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on November 18, 2022, to November 20, 
2022, billed with evaluation and management (EM) codes 99291-FS and 99292. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that payment for the billed services is included in 
the allowance for the surgical procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan says that the required modifier (FT) was not appended to the billed codes to indicate that the critical 
care visit is unrelated to the surgical procedure. However, the FT modifier would not be required in this case as 
the physicians are two different specialties, and the global period for surgery specifically excludes the services 
of another physician unless there's a transfer of care. As such, we find that the denial of payment on this basis is 
not substantiated. Therefore, we decided that the Plan has to pay for practitioner services provided on 
November 18, 2022, to November 20, 2022, billed with evaluation and management (EM) codes 99291-FS and 
99292.  
 
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 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 appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says the request for admission 
to an 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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. 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 Ilumya. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that this drug is necessary for the enrollee's condition. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Avastin/bevacizumab. 
 
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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Avastin. The reviewer found that there is no 
indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.