Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says that 4 additional physical 
therapy visits is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy visits. Our reviewer 
says that 4 additional physical therapy visits is medically necessary. Our physician reviewer found that the Plan 
has not provided medical records in support of its denial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have been met. Therefore, we decided that the Plan has 
to pre-approve 4 additional physical therapy visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's current condition and functional 
deficits, and multiple comorbidities, meets full inpatient acute rehabilitation criteria. The Plan denied your 
request. The Plan says the request does not meet guidelines for medical necessity because the current medical 
condition requires further evaluation and treatment in the acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction (D7210) for tooth #13, the deep 
sedation (D9222 and D9223), and the therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you need assistance to get your teeth 
removed and you are in pain. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the surgical extraction, the deep sedation, and the therapeutic parenteral drugs are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical extraction (D7210) for tooth #13, the deep sedation (D9222 and D9223), and the therapeutic parenteral 
drugs (D9612).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on January 6, 2023, to 
January 7, 2023, billed with procedure code 02RF38Z. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim is missing clinical trial information. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient claims for transcatheter aortic valve 
replacement, the provider must report value code D4 with the clinical trial number. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital care provided have not been met. We find that the clinical trial number was not reported on this claim as required. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital care provided on January 6, 2023, to January 7, 2023, billed with procedure code 02RF38Z.
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 is struggling at home. The Plan denied 
your request. The Plan says that the enrollee's condition does not meet Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is necessary because you are not 
ready to be treated on an outpatient basis and the IRF services will help you transition and function your own.  
The Plan denied your request. The Plan says the requested 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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you 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 you 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liver imaging, static only. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 the enrollee has a valid indication for magnetic resonance imaging (MRI) with and without contrast - 
procedure code 74183. Instead, by error, the wrong scan - a nuclear medicine test - was ordered. Procedure 
code 78201 corresponds to a code not indicated for the needed evaluation.  
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 liver imaging, static only.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home modifications (S5165) and sales tax (S9999) billed 
for dates of service June 29, 2022 to July 5, 2022. 
 
You asked the Plan to pay for the home modifications and sales tax. You say that this claim needs to be 
approved for reimbursement. You also say that you know of other members with the same policy group who 
have received reimbursement for a wheelchair ramp. The Plan denied your request. The Plan says the billed 
codes are invalid for Medicare purposes.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. Medicare rules also say that Medicare does 
not make separate payment for sales tax. 
 
We find that procedure codes S5165 and S9999 have Status Indicators of I on the Physician Fee Schedule. This 
means that procedure codes S5165 and S9999 are not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the home modifications and sales tax have not been met. 
Therefore, we decided that the Plan does not have to pay for the home modifications (S5165) and sales tax 
(S9999) billed for dates of service June 29, 2022 to July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was successfully treated with BiPAP and average volume-assured pressure support (AVAPS) 
while in the hospital. The provided primary-source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability, and failure of such a device has not been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222) provided on August 23, 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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit".  
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 99222 is 
not supported by the records provided. Our reviewer found that the documented history and documented 
examination are not comprehensive. As such, the billing of CPT 99222 is not supported. 
 
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 (99222) provided on August 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the home therapies would improve the 
enrollee's condition. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation shows that the enrollee has several conditions in which could result in mobility 
impairments but functional/mobility impairments are not well described thus clinical documentation does not 
show that the home health physical therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 29, 2022, to 
June 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 the 
diagnoses billed were correct. The Plan denied your request. The Plan says the billed principal diagnosis code 
K57.20 (Diverticulitis of large intestine with perforation and abscess without bleeding) and secondary 
diagnosis code K65.1 (Peritoneal abscess) as a secondary diagnosis are not supported. Combination code 
K57.20 (Diverticulitis of large intestine with perforation and abscess without bleeding) fully captures the two 
conditions without separate billing of secondary diagnosis code K65.1 (Peritoneal abscess). Therefore, this 
secondary diagnosis was removed, resulting in a lower DRG being 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 secondary diagnosis code K65.1 (Peritoneal 
abscess). 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 secondary diagnosis code K65.1 (Peritoneal abscess) is not 
supported by the medical record. Our physician reviewer found the history and physician on May 29, 2022, 
states that the patient is hemodynamically stable with no evidence of peritonitis. There is no mention of a 
peritoneal abscess, just the abscess of the large intestine which is captured with diagnosis code K57.20. K65.1 
is not supported as a secondary diagnosis.  
 
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 May 29, 2022, to June 13, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a hypoglossal nerve neurostimulator array. 
 You asked the Plan to pre-approve hypoglossal neurostimulator. You say that this can significantly enhance 
your health. The Plan denied your request. The Plan says you do not have a BMI of less than 35 and data for 
continuous positive airway pressure usage was not provided. 
 
The Plan follows Medicare rules. Medicare rules state that hypoglossal nerve stimulation for the treatment of 
obstructive sleep apnea is only covered if certain criteria are met. 
 
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 hypoglossal neurostimulator. Our 
reviewer says that you do not meet criteria for this device. Our physician reviewer found you have moderate 
obstructive sleep apnea and are intolerant to continuous positive airway pressure. Your body-mass index (BMI) 
on April 5, 2023 was 35.77. Sleep endoscopy documented absence of complete concentric upper airway 
collapse. You do not meet the coverage indications because your BMI is not less than 35. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hypoglossal neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of a hypoglossal nerve neurostimulator array.
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. The Plan denied your request. The Plan says the enrollee's records 
do not show you need an intensive team (rehab doctor and nurse, social worker, and therapists) for your care. 
Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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.