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

 
We decided that the Plan does not have to pay for outpatient hospital services provided from July 24, 2023, to 
July 26, 2023. 
 
You asked the Plan to pay for outpatient hospital services. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says there are multiple I/OCE edit errors 
on this claim which mean payment cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that The Plan must follow Medicare rules. Medicare 
rules say that providers must report services correctly. Providers must report services with the appropriate CPT 
code. The rules also say that when an inpatient-only procedure is reported on an outpatient claim, that line item 
is denied with I/OCE edit 18. All other line items billed for the same date are denied with I/OCE edit 49. In 
addition, when a claim consists of a combination of lines which are all either denied or rejected or packaged, 
those lines are denied under edit 47.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient hospital services have not been met. Specifically, the laparoscopy billed with code 
44188 for date of service July 24, 2023, has a status indicator of C and does not meet the exception to the rule. 
This means that code 44188 is denied with I/OCE edit 18, and all other codes reported for the date of service 
July 24, 2023, are denied with edit 49. The codes billed for dates of service July 25, 2023, to July 26, 2023, 
(36415, 86850, 86901, 86920, 80053, 82728, 83540, 84466, 85025, 85027, P9016, J1650, J2916 and J7120) 
are considered packaged services which would be denied under edit 47 in this case. Therefore, we decided that 
the Plan does not have to pay for outpatient hospital services provided from July 24, 2023, to July 26, 2023.
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve home health skilled nursing care. We decided that the Plan does 
not have to pre-approve occupational and physical therapies.  
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration for 
the denied claim. The Plan says that you do not meet the requirements for approval. 
 
We decided that the Plan has to pre-approve home health skilled nursing care.  
 
The Plan follows Medicare rules. Medicare rules say that the patient must be under the care of a physician or 
allowed practitioner.  
 
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 item/service at issue. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the enrollee does require wound care 
for multiple diabetic partial thickness wounds on the left and right feet.  
 
Therefore, the continued home health skilled nursing care is 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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve home health skilled nursing care.  
 
We also decided that the Plan does not have to pre-approve occupational and physical therapies. 
 
The Plan follows Medicare rules. Medicare rules say that the patient must be in need of physical therapy or/and 
occupational therapy. 
 
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 item/service at issue. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee is noted to be 
medically stable. The enrollee has been educated regarding their medications and they have not recently been 
hospitalized. The enrollee requires very little assistance (contact guard assistance) with mobility and daily 
activities and their level of mobility has not significantly changed with physical therapy. 
 
Therefore, the continued home health skilled nursing care is medically necessary and the occupational and 
physical therapies are 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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve occupational and physical therapies. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will require 24-hour medical oversight 
to manage and improve issues related to new and existing conditions related to recent hospital admittance. The 
Plan denied your request. The Plan says based on the available information, admission to IRF is not reasonable 
and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a pathological tibial fracture and evaluation of a lung mass. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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 physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the requested services can be provided 
by an in-network provider. 
 
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 record shows you are 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 physical 
therapy services to be provided by an OON provider.
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 needs IRF services to become mobile 
again. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF 
admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced foot and ankle feature 
(L5986, L5987). 
 
You asked the Plan to pre-approve prosthetic leg with advanced foot and ankle feature. You say that the 
requested prosthetics are medically necessary. The Plan denied your request. The Plan says the request for a 
prosthesis with K3 foot does not meet Medicare criteria as reasonable and 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 prosthetic leg with advanced foot and 
ankle feature. 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 a transtibial amputation. There is 
evidence he is expected to be a K3 ambulator. The microprocessor ankle foot system is not medically necessary 
for K3 ambulation based on survey of literature and clinical practice standards. Per Social Security 
Administration (SSA) 1862 (a)1(A), the requested device is not standard of care and has not been shown to be 
as effective as standard 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 prosthetic leg with advanced foot and ankle feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with advanced foot and ankle 
feature (L5986, L5987).
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 was independent but now is lying in a 
bed needing care and to get back to baseline. The Plan denied your request. The Plan says that the necessary 
services can be provided in other settings.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. 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.  
 
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 the enrollee's needs require IRF and close physician 
supervision in order to regain maximum function. The Plan denied your request. The Plan says that there is no 
need for an intensive rehabilitation program.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. 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.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says at the time of appeal, you have two remaining trips 
allowed. Additional trips are not covered once the benefit has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and receiver. 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin or has a history of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) and receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Helicoll, per square centimeter (cm) (Q4164) and under 
skin substitute grafts (15271). 
 
You asked the Plan to pre-approve skin substitute. You say that the requested items are medically necessary. 
The Plan denied your request. The Plan says there are limited studies related to Helicoll for wound treatments, 
second degree burns, and chronic ulcers. Therefore, it is not possible to conclude whether Helicoll has a 
beneficial effect on health outcomes. They are experimental and investigative. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this case pertains to an enrollee with a stage 3, full thickness left heel pressure ulcer measuring 
4 x 2.5 x 2 cm. The wound is noted to have moderate purulent drainage and 25-50% yellow necrotic tissue. 
Helicoll as a skin substitute is considered investigational. Regardless, skin substitutes in general are not 
approved for wounds with active infection and necrotic tissue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Helicoll, per square centimeter (cm) (Q4164) and under skin substitute grafts (15271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87498, 87634, and 
87798) rendered on January 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim had incorrect billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 The CPT code manual definition of the denied codes is: 
 
CPT 87498: 
 
Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes 
reverse transcription when performed 
 
CPT 87634: 
 
Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe 
technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, in terms of CPT 
87498 and 87634, a more appropriate panel code should have been reported for these services. In terms of CPT 
87798, this represents a "not otherwise specified" procedure. The documentation does not include the tests 
being reported for this code. Therefore, the code and the units 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 87498, 87634, and 87798) rendered on January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric 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 psychiatric 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 December 27, 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 psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.