Persius/hicric huggingface dataset:
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 requires acute inpatient rehabilitation in 
the effort to facilitate increased independence and to return home with an imporved quality of life. The Plan 
denied your request. The Plan says an IRF admission is not medically 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 requires intensive inpatient rehabilitation 
with daily physician management, 24-hour specialized rehab nursing , and intensive therapies to optimize 
mobility and strength. The Plan denied your request. The Plan says an IRF admission is not medically 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) and injection services 
(J2250) billed for date of service April 18, 2023. 
 
You asked the Plan to pay for codes 99152 and J2250. You say that the records provided support the codes 
billed. The Plan denied your request. The Plan says the codes in dispute are not supported. 
 
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 J2250 is for injection, midazolam hydrochloride, per 1 
milligram (mg). The CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 codes 99152 and J2250. Our reviewer says that the medical 
records do not include sufficient documentation to support the services billed. Our reviewer found the sedation 
records submitted do not include clear documentation of medication for anesthesia given, or information 
regarding dosage. Therefore, the J2250 code billed cannot be verified. The clinical records also do not include 
documentation of the enrollee requiring the presence of an independent trained observer for 15 minutes of 
intraservice time. Therefore, the 99152 code criteria 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 codes 99152 and J2250 have not been met. Therefore, we decided that the Plan 
does not have to pay for moderate sedation services (99152) and injection services (J2250) billed for date of 
service April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on March 13, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are covered. The Plan 
denied your request. The Plan says you did not provide a referring provider's name in Box 17 of the claim 
form.  The Plan has reached out to you four separate times to get this corrected, with no response. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the name of the referring or 
ordering physician if the service or item was ordered or referred by a physician in Box 17 of the claim form.  
You have not entered a referring provider's name in the box, despite multiple requests from the Plan to get you 
to fix this error. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound care supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for wound care supplies provided on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 9, 2022, to 
September 10, 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 you 
agree that secondary diagnosis code J96.01 should be removed; however, you feel that the principal diagnosis 
code A41.9 is supported.  The Plan denied your request. The Plan says the DRG was adjusted as two codes 
were not supported by the record. 
 
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 diagnosis code A41.9 is not supported in the 
medical record.  Our physician reviewer found the enrollee presented with shortness of breath following a 
recent COVID-19 infection. The enrollee responded promptly to standard therapy and was discharged after one 
midnight of care. There is no evidence of sepsis (hypotension, hypoperfusion, organ failure) in 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 9, 2022, to September 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93653, 93655, 93655-59 and 93462 billed for date of 
service March 31, 2023. 
 
You asked the Plan to pay for codes 93653, 93655, 93655-59 and 93462. You say that these services were 
medically necessary and were reported appropriately. The Plan denied your request. The Plan says these 
services are not supported in the medical records. 
 
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 93653 is comprehensive electrophysiologic evaluation 
including insertion and repositioning of multiple electrode catheters with induction or attempted induction of 
an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), 
and His bundle recording (when necessary). The CPT Code Manual definition of code 93655 is intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, 
including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (Listed separately in 
addition to code for primary procedure). The CPT Code Manual definition of code 93462 is left heart 
catheterization by transseptal puncture through intact septum or by transapical puncture (Listed separately in 
addition to code for primary procedure). 
 
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 codes 93653, 93655, 93655-59 and 93462. Our reviewer says 
that the criteria for coverage have not been met. Our reviewer found a comprehensive electrophysiologic (EP) 
study involves the provider placing wire electrodes in the heart to measure electrical activity. The provider 
induces, or attempts to induce, arrhythmia. The provider also treats rapid heartbeat that originates above the 
ventricles by destroying the pathway or other source of the problem. We are unable to cite the report, as this 
procedure was not found in the medical record. Therefore, code 93653 cannot be verified. The procedure report 
does not include documentation of intracardiac catheter ablation of a discrete mechanism of arrhythmia which 
is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous 
or induced arrhythmia. Therefore, codes 96355 and 96355-59 cannot be verified. The procedure report also 
does not include documentation of left heart catheterization by transseptal puncture through intact septum or by 
transapical puncture. Therefore, code 93462 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 codes 93653, 93655, 93655-59 and 93462 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 93653, 93655, 93655-59 and 93462 billed for date of 
service March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 office visits to be provided by an out-of-network 
(OON) provider.  
 You asked the Plan to pre-approve 6 office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 6 office visits to be provided by an OON provider. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the 6 additional OON University of Washington radiation oncology visits at 
issue in this case meet all Medicare criteria for medically reasonable and necessary for the enrollee as opposed 
to follow-up with an in-network provider. It is medically reasonable to await the results of the evaluation with 
the OON provider to determine if further OON services are indicated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 office visits to be provided by an OON provider have not been met.  
 
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 6 office visits to be provided by an OON provider. 
Therefore, we decided that the Plan does not have to pre-approve 6 office visits to be provided by an out-of-
network (OON) provider.
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 meets criteria for LTAC 
medically complex patient. The appellant says the enrollee requires a milt-disciplinary approach to help 
manage her medically complex issues.  The Plan denied your request. The Plan says the LTACH services are 
not medically necessary, and the enrollees needs are being met in the current hospital facility.  
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physician oversight and 
intensive rehabilitation therapy. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5-S1 allograft injection services. 
 
You asked the Plan to pre-approve L5-S1 allograft injection services. You say that Via Disc is appropriately 
indicated for the enrollee. The Plan denied your request. The Plan says there is little evidence in medical 
literature to suggest that this is appropriate. 
 
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 L5-S1 allograft injection services. Our 
reviewer says that the requested L5-S1 allograft injection services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has 
failed conservative therapy including physical therapy and medication trials. Imaging shows multi-level 
degenerative changes and annular fissure at L5-S1. Allograft injection services, such as the requested Via Disc, are considered experimental and investigational.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5-S1 allograft injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve L5-S1 allograft injection 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 need rehab services as soon as possible to 
prevent further atrophy. The Plan denied your request. The Plan says you do 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that the service should be covered, and that the 
enrollee qualifies for it. The Plan denied your request. The Plan says there are not enough studies to show that 
Vertiflex Superion is safe and effective to treat back pain. 
 
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 Vertiflex Superion. Our reviewer says 
that the requested items/services is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. This 
enrollee has multiple degrees of spinal stenosis, many not at the food and drug administration (FDA) indicated 
levels of moderate spinal stenosis including the planned level of implantation of  lumbar vertebrae (L)4-5. 
The FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been 
adequately addressed in the medical records. There is imaging evidence of L4-5 anterolisthesis with no 
discussion of spinal instability on flexion/extension films. There is no discussion of scoliosis of the lumbar 
spine with no documentation of the Cobb angle. There is no discussion indicating that a dual x-ray 
absorptiometry (DEXA) scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found genicular nerve ablation is considered 
experimental therapy and is the subject of ongoing clinical trials. The services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve ablation.