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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 9, 2022, to 
November 13, 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 E43 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says E43 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 E43, defined as severe protein-
calorie malnutrition. 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 E43 is not supported in the 
medical record. Our physician reviewer found the enrollee is a 73-year-old who was treated in the hospital for 
an acute stroke. The provided documentation did not sufficiently support the enrollee had malnutrition related 
to their treatment during this visit. There was no report of significant weight loss or reduced food intake. The 
enrollee did not have objective signs of malnutrition, such as muscle wasting and low albumin. They were 
tolerating a pureed diet.  
 
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 November 9, 2022, to November 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver (64590) and an open implantation of neurostimulator electrode 
array; sacral nerve (64581). 
 
You asked the Plan to pre-approve an implantation of neurostimulator electrode array. You say that the enrollee 
is in need of the requested treatment. The Plan denied your request. The Plan says the records do not show why 
a full open exposure of the sacrum for direct visualization of lead placement is necessary rather than the 
standard percutaneous approach. 
 
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 an implantation of neurostimulator 
electrode array. 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 incomplete bladder emptying, 
overactive bladder, urge incontinence, frequency, and urgency. She failed medical management with beta 
agonists and oxybutynin. On October 18, 2023, she had a PNE (percutaneous nerve evaluation) trial. She had 
>60% improvement in her symptoms. The enrollee does not meet criteria for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantation of neurostimulator electrode array have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of peripheral or 
gastric neurostimulator pulse generator or receiver (64590) and an open implantation of neurostimulator 
electrode array; sacral nerve (64581).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as minimally invasive 
treatments have not provided relief. The Plan denied your request. The Plan says this procedure is considered 
experimental and investigational, and has not been proven to be beneficial. 
 
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 this is considered an experimental/investigational procedure.  Therefore, the request is deemed not 
medically reasonable and 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 genicular artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 13, 2023, to June 20, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 13, 2023, to June 
20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EEG provided on April 26, 2023. 
 
You asked the Plan to pay for the EEG. You say that the EEG was medically necessary. The Plan denied your 
request. The Plan says the EEG is experimental or 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 pay for the EEG. Our reviewer says that the 
requested EEG is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of EEG during lumbar spine surgery is not clearly 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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for an EEG provided on April 26, 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 enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current facility until 
they are more stable for transfer to another level of care. 
 
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.  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (K0856, 
E1028, E1002, E2311, E1012, E2361, E1028, E2620, E0955, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
is medically necessary due to the enrollee's right sided heart failure and incontinence. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for power tilt option included with a K0856 
group 3 power wheelchair. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for 
mobility. The enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness. She 
requires a power wheelchair for mobility and accomplishing her daily activities. However, the clinical 
documentation is insufficient why a lower-level power wheelchair would not meet the enrollee's needs versus a 
group 3 power wheelchair. There is inadequate clinical documentation regarding why she requires power tilt 
and cannot adequately perform pressure relief. There is no history of skin breakdown. A group 3 power 
wheelchair base is typically indicated in enrollees with significant paralysis due to conditions such as a spinal 
cord injury. Therefore, the group 3 power wheelchair with tilt 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (K0856, E1028, 
E1002, E2311, E1012, E2361, E1028, E2620, E0955, E2607).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the clinical documentation does not support that the complexity of the enrollee's
nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The documentation does not support that the enrollee required treatment by
multiple therapies and an intensive rehabilitation therapy program of at least 3 hours a day for 5 days a week,
or 15 hours over 7 consecutive days, of therapy services. Documentation does not support that the intensive
rehabilitation therapy program provided in an IRF was medically reasonable and necessary for the enrollee in
this case. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 7, 2022, to 
November 8, 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 secondary diagnosis code G93.41, described as 
metabolic 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee presented with altered mental status. He was found to 
have hypoglycemia and responded to the administration of sugar. There is no evidence that the enrollee had 
any other cause of altered mental status. Therefore, a secondary diagnosis of G93.41 is not supported.  
 
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 November 7, 2022, to November 8, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the respite care provided from September 10, 2022, to 
September 21, 2022. 
 
  You asked the Plan to pre-approve the respite care. You say that the enrollee has already paid the providers out 
of pocket, but the claim was not paid by the Plan due to an error. You also say that the claim payment should 
be processed in order to get reimbursed by the out-of-pocket payment made to provider. The Plan denied your 
request. The Plan says the documents do not show a problem with the enrollee's lab values as states in the 
reason for needing respite care. 
 
The Plan must follow Medicare rules. Medicare rules say that respite care may only be provided in a Medicare-
participating hospital or hospice inpatient facility, or a Medicare or Medicaid participating nursing facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respite care have not been met. Specifically, the record shows that the enrollee was not enrolled 
in hospice care during these dates of service. Therefore, we decided that the Plan does not have to pre-approve 
the respite care provided from September 10, 2022, to September 21, 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 enrollee needs acute therapy at a skilled nursing 
facility. The Plan denied your request. The Plan says based on the available information, admission to an IRF is 
not reasonable and 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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. Our reviewer also found that the enrollee requires treatment by multiple therapies, 
including physical therapy and occupational therapy, but this can be provided in a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 will need intensive physical and occupational 
therapy and you are on dialysis as well. You say you live alone and your home is not large enough for you to 
have a wheelchair in your home. The Plan denied your request. The Plan says you do not meet Medicare 
guidelines for services in an inpatient rehabilitation facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although you need 
physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of your condition 
doesnt require an IRF stay and care can be provided in a lower level.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says this request will exceed the 
maximum number of transportation trips allowed per year. 
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request will exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac joint injections. 
 
You asked the Plan to pre-approve bilateral sacroiliac joint injections. You say that the enrollee has pain over 
the SI joint bilaterally and requires the requested procedure. The Plan denied your request. The Plan says the 
requested procedure does not meet the criteria for approval. 
 
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 bilateral sacroiliac joint injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee does not have at least three positive findings with 
provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction, 
or Yeoman Tests. The review has determined that the enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral sacroiliac joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral sacroiliac joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 16, 2022. 
 
You asked the Plan to pay for the medical services. You say that you filed the original claim timely. The Plan 
denied your request. The Plan says you did not submit a corrected, final claim until after the time limit had 
passed.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 
2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for 
the medical services was not filed until June 16, 2023. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided 
on April 11, 2023, to April 20, 2023. 
 
You asked the Plan to pay for the inpatient rehabilitation facility (IRF) services. You say that the service 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 inpatient 
rehabilitation facility (IRF) services provided on April 11, 2023, to April 20, 2023.