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 is stable and has strong 
criteria for LTACH admission and is ready to transition to that level of care for pulmonary and medical 
management. The appellant says the enrollee is ready to start aggressive rehabilitation so they can return home 
safely.  The Plan denied your request. The Plan says the LTACH services are not medically necessary, and the 
enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer. 
 
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 was admitted for scheduled composite anterior marginal mandibulectomy with subtotal glossectomy, neck dissection and flap reconstruction secondary to head and 
neck cancer. 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 he is not currently receiving but that 
would be available at the LTACH facility.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation. 
 
You asked the Plan to pre-approve peripheral nerve stimulation. You say that it is medically necessary. The 
Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve peripheral nerve stimulation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found This is considered experimental therapy.  It is the subject of ongoing 
clinical trials.  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 peripheral nerve stimulation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not require multiple power options.  
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has Parkinsons Disease and muscular dystrophy. He has impaired ambulation 
and requires an assistive device to stand. His condition is chronic, and he has intact skin. He has grade 3 out of 
5 strength in his upper extremities. However, the enrollee does not meet the coverage criteria for the tilt and 
recline options. The enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. Therefore, the request is not medically 
necessary in this case. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee did not progress on carboplatinum and 
pemetrexed. The Plan denied your request. The Plan says Opdivo is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that Opdivo 
is not medically necessary. Our physician reviewer found that the requested use of Opdivo is not FDA-
approved. Opdivo is also not supported by one of the major drug compendia or by clinical research. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an 
LTACH to regain prior level of functioning and continue multi-disciplinary approach to care.  The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. 
 The Plan denied your request. The Plan says there are not complicated wounds or multiple complicated 
medications which cannot be given in the current location, the enrollee can remain in the current acute care 
location until such time no further acute level care is needed. 
 
 
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: 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 admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee is currently at home getting home health and is 
confined due to illness, needing the aid of supportive devices such as crutches, canes, wheelchairs, and walkers. 
There is no skilled needs identified for the enrollee, services needed are custodial care.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease detection panel provided on August 5, 
2022, billed with multiple codes.  
 
You asked the Plan to pay for the infectious disease detection panel as billed. You say that this testing was 
medically necessary as ordered by the physician.  The Plan denied your request. The Plan says this panel was 
not billed with a single code as required.  
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that testing panels should be billed with a single code 
with one UOS. Therefore, we decided that the Plan does not have to pay for the infectious disease detection 
panel provided on August 5, 2022, billed with multiple codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2023, billed with 
codes 81226-GY and 81291-GZ.  
 
You asked the Plan to pay for the testing as billed. You say that this testing is covered by Medicare. The Plan 
denied your request. The Plan says these were billed with modifiers resulting in denial.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that modifiers -GY and -GZ are used for services 
expected to be denied.  
 
Though the provider argues these tests are covered, they were billed with modifiers supporting the denial.  
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 25, 2023, 
billed with codes 81226-GY and 81291-GZ.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the nerve block procedure provided on March 31, 2023, billed with 
code 64450-59. 
 
You asked the Plan to pay for the nerve block as billed. You say that this code should be paid. The Plan denied 
your request. The Plan says that the medical records do not support procedure code 64450 as a distinct 
procedural service from procedure code 01214. 
 
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, we have confirmed that code 64450 is a column II code to column I code 01214; however, 64450 
was billed with a modifier.  
 
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 nerve block as billed. Our reviewer says that the records 
support that the modifier was correctly used to bypass the edit. Our reviewer found there is documentation to 
support 64450, as this a pain block for after the hip replacement procedure occurred. This is for post operative 
pain management and was not related to the anesthesia.  
 
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 nerve block as billed have been met. Therefore, we decided that the Plan has 
to pay for the nerve block procedure provided on March 31, 2023, billed with code 64450-59.  
 
 
 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 pay for inpatient hospital services provided on September 16, 2022, to 
September 22, 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 this 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says that the record does 
not support that A41.9 was the appropriate principal diagnosis for this hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the record supports the reported principal 
diagnosis of A41.9. Our physician reviewer found the patient presented to the hospital with infection from 
enterocolitis and urinary tract infection. The patient had documented tachycardia, tachypnea, and leukocytosis 
to 15,000. This meets the criteria for systemic inflammatory response syndrome with a urinary source of 
infection, so code A41.9 is justified. 
 
 
 
 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 inpatient 
hospital services provided on September 16, 2022, to September 22, 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: 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 LTACH is medically necessary.  The 
Plan denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee's 
continued care needs are being met in the current hospital. 
 
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 was admitted with acute hypoxemic respiratory failure secondary to 
interstitial infiltrates. The record indicates that the enrollee is improving but still requires acute care services 
before transitioning to a lower level of care. 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 he is not 
currently receiving but that would be available at the LTACH facility.   
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a high intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve the requested testing. You say that the service will determine the enrollee's 
cancer treatment option. The Plan denied your request. The Plan says that there is no documentation of 
recurrence of prostate cancer after radiation treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested testing. Our physician 
reviewer found that the enrollee has adenocarcinoma of the prostate. High Intensity Focused Ultrasound 
(HIFU) treatment of the prostate is neither experimental nor investigational. More than 100 clinical studies 
have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of 
side effects such as impotence, urinary incontinence, and bowel injury. Therefore, the requested high intensity 
focused ultrasound (HIFU) is medically reasonable and necessary in this case. 
 
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 requested testing have been met. Therefore, we decided that the Plan has to 
pre-approve a high intensity focused ultrasound (HIFU).  
 
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: Favorable

 
We decided that the Plan has to pre-approve a transfer board (E0705). 
 
You asked the Plan to pre-approve a transfer board. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this is not a covered item. 
 
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 did not provide a clear denial reason or any supporting evidence for the 
denial. Therefore, we decided that the Plan has to pre-approve a transfer board (E0705).  
 
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 the enrollee is stable and suitable for 
transfer to a LTACH. You also say that the enrollee cannot be adequately cared for in their current condition at 
a skilled nursing facility or any lower level of care. The Plan denied your request. The Plan says based on 
Medicare guidelines, the LTACH services requested do not meet the requirements for approval.  
 
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 coverage rules are not satisfied. 
 
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.