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 you prefer to be admitted to rehabilitation because 
you want to regain your independence.  The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare 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 that you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary because the 
enrollee has a serious, life-threatening constellation of acute medical problem that have left them at a functional 
status below their baseline. The Plan denied your request. The Plan says admission to an IRF 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 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. While the enrollee may have a need for physical 
therapy 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 this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support a need for cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollee's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a stance flexion feature. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this feature is included in the approved 
knee (L5814). 
 
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 stance flexion feature. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the request exceeds the enrollee's needs as the stance control adjustable feature is 
included in the already approved code, L5814.  
 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 stance flexion feature have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stance flexion feature (L5845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says although there are 
three requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these 
power options through the joystick. 
 
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 electronic connection, harness, and 
expandable controller. 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 multiple sclerosis (MS) 
which impairs their ambulation. The enrollee has used a power chair since 2019 and is now requiring repair or 
replacement. Our reviewer found that the enrollee is able to play pool and fish, using the power wheelchair. 
The enrollee has 5 out of 5 strength in their upper extremities. Our physician reviewer also found that the 
enrollee has adequate upper body strength to manage standard power drives. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on January 18, 2023. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the billed code is 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 J3490 is "Unclassified drugs". 
 
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 drugs. Our reviewer says that the use of code J3490 is not 
supported by the records provided. Our reviewer found that the procedure report describes baclofen with sterile 
water for injection. This is not considered a compounded drug, and therefore a more appropriate code should be 
reported for service provided.  
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pay for the drugs (J3490) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5130) purchased on 
January 3, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5130) purchased on January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (22869).  
 
You asked the Plan to pre-approve an interspinous device. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says there is a lack of evidence (only a retrospective series) on the 
efficacy of interspinous fixation devices as a stand-alone procedure for those who have spinal stenosis and/or 
spondylolisthesis.  
 
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 interspinous device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that interspinous devices are experimental. More research is needed.  
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 interspinous device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device 
(22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hemoglobin; glycosylated (A1C) testing rendered on January 
30, 2023. 
 
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 Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the limited provided documentation did not show a prior abnormal glucose, physical findings or 
symptoms suggestive of possible diabetes to justify this test as required. Therefore, without sufficient support 
made, this request for hgb A1C testing will be considered not medically necessary based on the provided 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hemoglobin; glycosylated (A1C) testing rendered on January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for shoulder surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation provided to support the expectation that the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
admitting physician reasonably expects that the enrollee's necessary inpatient hospital care will span two 
midnights for a left shoulder reverse arthroplasty procedure for treatment of degenerative osteoarthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for shoulder surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99231 and 99233 rendered from January 6, 2023, to 
January 9, 2023. 
 
You asked the Plan to pay for the services. You say that all of the diagnosis codes on the claim were coded 
correctly. The Plan denied your request. The Plan says that the diagnosis codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that Excludes1 is used when two conditions cannot occur together, such as a congenital form versus 
an acquired form of the same condition.  An exception to the Excludes1 definition is the circumstance when the 
two conditions are unrelated to each other. 
 
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 supported by the medical records. Our reviewer found that the enrollee presented to the hospital 
following cardiac arrest, with a related fall fracturing the C7 cervical vertebrae. Also noted on imaging was a 
chronic T5 fracture. It was unrelated and was pathological. Therefore, the two fractures and associated codes 
appear to not be related to each other, based on the provided documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Our review found that the two diagnosis codes 
are unrelated to each other. This satisfies the criteria to warrant an exception to the Excludes1 rules. Based on 
this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 99231 and 99233 rendered from January 6, 2023, to 
January 9, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not meet criteria, and the enrollee has an approved physiatry 
authorization. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the the mobility evaluation does not indicate the cause of the patients paralysis and why a 
specialized ultralight weight manual wheelchair is needed versus a lightweight or standard manual wheelchair. 
A referral was made to physiatry regarding the need for an ultralightweight manual wheelchair, but no 
evaluation is provided. Therefore, the ultralight manual wheelchair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultra lightweight manual wheelchair (K0005).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95822) provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only". 
 
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 use of code 95822 is 
not supported by the records provided. Our reviewer found that the medical record describes a neuromonitoring 
service provided for anterior cervical discectomy and fusion at C4-C7. In this case, there is a more appropriate code to report for service provided. 
 
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 the services (95822) provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulation (PNS) device. 
 
You asked the Plan to pre-approve the Sprint PNS device. You say that please review and process the attached 
clinicals for authorization appeal. The Plan denied your request. The Plan says percutaneous peripheral nerve 
stimulation (PNS) is unproven and not medically necessary due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sprint PNS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Sprint peripheral nerve stimulation (PNS) device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 16, 2021, to July 
20, 2021, 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 
medical records support the diagnosis billed. The Plan denied your request. The Plan says the medical records 
did not support the billed principal diagnosis of A41.9 (Sepsis, unspecified organism). As a result, a lower 
DRG was paid. 
 
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 a principal diagnosis of A41.9 (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 billed principal diagnosis of A41.9 (Sepsis, unspecified 
organism) is not supported by the medical record. Our physician reviewer found the enrollee presented with 
altered mental status.  He was found to have a urinary tract infection and mild dehydration/acute kidney 
infection.  There is no evidence of hypotension, hypoperfusion or organ failure.  As such, a diagnosis of sepsis 
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 July 16, 2021, to July 20, 2021, at the Diagnosis Related Group 
(DRG) originally billed.