Persius/hicric huggingface dataset:
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 currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
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 current acute care setting as provided by 
the Plan. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 7, 2023, to 
January 10, 2023, 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 N17.0 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says N17.0 is not supported in the documentation. 
 
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 secondary diagnosis code N17.0, defined as acute 
kidney failure with tubular necrosis. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that secondary diagnosis N17.0 is 
not supported in the documentation. Our physician reviewer found the enrollee is a 95-year-old with chronic 
kidney disease stage 3 who presented to the emergency department with weakness, cough, headache, and was 
diagnosed with Influenza A. Workup revealed creatinine of 1.41 milligram (mg)/deciliter (dL) and blood urea 
nitrogen (BUN) of 30 mg/dL. Post intravenous (IV) fluid administration creatinine was 1.0 mg/dL. The 
enrollee's baseline creatinine was around 0.5 mg/dL. However, the enrollee did not meet criteria for acute 
kidney failure due to not requiring continuous renal replacement therapy (CRRT) or hemodialysis and not 
having a rise in creatinine of 1.5 times the baseline or more than 0.1 mg/dL during the course of treatment. The 
enrollee didn't have significant oliguria or evidence of urine findings confirming acute tubular necrosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 7, 2023, to January 10, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 29, 2022, 
to October 4, 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 
patient met the criteria for the diagnoses billed. The Plan denied your request. The Plan says the billed 
diagnoses of A41.89 (other specified sepsis) and R65.20 (severe sepsis without septic shock) are not supported 
by the medical record. As a result, a lower DRG was paid. The Plan states that reasonable clinical evidence 
within the health record must be present to clinically validate the diagnoses, and it is not present for these two 
diagnoses. 
 
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 diagnoses of A41.89 (other specified sepsis) and 
R65.20 (severe sepsis without septic shock). 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 diagnoses of A41.89 (other 
specified sepsis) and R65.20 (severe sepsis without septic shock) are not supported by the medical record. Our 
physician reviewer found the patient is a 60-year-old male with end-stage renal disease (ESRD) who was 
treated in the hospital from September 29, 2022, to October 4, 2022, for C diff infection and was started on 
antibiotics and fluids. Initial workup revealed leukocytosis, Creatinine 5.4, BUN 22, and borderline low blood 
pressure, but had normal platelet count, normal bilirubin, no hypoxia, no oliguria, and was alert and oriented. 
As the patient had ESRD, the Creatinine level was not unexpected. The Sequential Organ Failure Assessment 
(SOFA) score was 1 due to lower blood pressures, however, no other evidence of organ failure was noted 
related to a dysregulated response to systemic infection. Sepsis 3 criteria was not met. Therefore, the billed 
diagnoses of A41.89 (other specified sepsis) and R65.20 (severe sepsis without septic shock) are not supported 
by the medical record.  
 
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 29, 2022, to October 4, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 09, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on June 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-waterproof tape (code A4450). 
 
You asked the Plan to pre-approve the requested supplies. The Plan denied your request. The Plan says the 
request is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that ostomy supplies are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records show that 600 units of code A4450 was requested for a 
3-month supply. The Plan approved 240 units, which is 40 per month for 6 months. The remaining 340 codes 
have not been shown to be necessary. The documentation does not provide rationale as to why excess units are 
necessary in this case.  Based on this information, we decided that Medicare rules for coverage of the requested supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve additional non-waterproof tape (code 
A4450).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower back. 
 
You asked the Plan to pre-approve the MRI . You say that your condition will no improve with physical 
therapy and your pain continues to increase with time. The Plan denied your request. The Plan says you have 
not had six weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found detailed documentation regarding a trial and 
failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. You had a 
trigger point injection on April 24, 2023, with no follow-up examinations provided to corroborate if any benefit 
had been reached with that injection. There is no documentation of any formal therapy or consistent use of 
medications for low back pain. Additionally, there are no objective deficits documented on a providers 
examination to support lumbar pathology. Moreover, there are no recent plain lumbar x-rays that are non-
diagnostic. 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower back.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
March 30, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service February 6, 
2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the method of testing has not been documented. 
 
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 G0481 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
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 procedure code G0481. Our reviewer says that procedure 
code G0481 does not meet criteria for payment. Our reviewer found that the record states that more than 14 
drug classes were tested. The documentation does not support that G0481 was coded to the highest specificity. 
There is a more specific code for the tests performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0481 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0481 billed for date of service February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00731) performed on 
March 14, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's diagnosis does not require anesthesia 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 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 enrollee had a history of obesity, hypertension, rheumatoid arthritis who was referred for 
endoscopy with anesthesia care. This procedure does not require anesthesia care and anesthesia 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 00731) performed on March 14, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 has had a drastic decline in their 
mobility and needs services to return to their baseline independence and maintain quality of life. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollee's condition is complex and fragile, and there is every reason to expect that they will 
participate in and benefit from IRF services to include at minimum physical, speech and occupational therapy, 
physician oversight of neurological symptoms and polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return, as well as avoid further preventable 
readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation facility admission is 
approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Favorable

 
We decided that the Plan has 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 unable to care for self and your doctor says 
that the next 6 weeks are critical to your recoevery from your hip replacement. The Plan denied your request. 
The Plan says the services you need can be provided safely in another setting such as a skilled nursing facility, 
home with home health services, or home with outpatient therapy. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. Your condition is complex, and there is every reason to expect that you will participate in and 
benefit from IRF services to include at minimum physical and occupational therapy, physician oversight of 
wound care and polypharmacy, and case manager coordination of any additional services that might be needed 
to make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. Therefore, 
the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lift Chair (E0627), purchased on April 21, 2023.  
 
You asked the Plan to pay for the lift chair. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Lift Chair (E0627), purchased on 
April 21, 2023.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving the appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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.