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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 28, 2023, 
through March 7, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 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 this hospitalization does not qualify for inpatient payment under the two-midnight 
rule. While the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to 
expect that two midnights of inpatient level care would be medically necessary. There is no documentation of 
uncontrolled co-morbidities and no documentation of procedural/post-procedure complications, which were 
clearly going to necessitate a prolonged (that is, two midnight) stay. 
 
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 the acute inpatient hospital care provided February 28, 2023, through March 7, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq (J9022). 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee's condition was previously treated with 
adjuvant systemic chemotherapy of Carboplatin and Paclitaxel weekly with radiation. The Plan denied your 
request. The Plan says the requested use of this drug is not approved by the Food and Drug Administration 
(FDA) for the enrollee's condition. 
 
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 Tecentriq. Our reviewer says that the 
requested use of Tecentriq is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of presumed second primary stage III squamous cell carcinoma of the lung, PDL-1 
negative. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. Therefore, the reviewer found that the requested use of Tencentriq is not 
medically reasonable or 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq (J9022).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the enrollee was assessed and 
needs the requested power wheelchair. The Plan denied your request. The Plan says the notes do not show that 
the enrollee's mobility limitation is due to severe nerve (neurological) disease, muscle disease (myopathy) or 
bone deformity from birth. 
 The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair may be covered when 
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 a Group 3 power wheelchair. Our 
reviewer says that the requested Group 3 power wheelchair is not medically necessary. Our physician reviewer 
found the provided records indicate that the enrollee has a history of lumbar spine fusion surgery. The enrollee 
was noted to have no acute neurological deficits and no edema in the lower extremities. The reviewer found 
that the enrollee is noted to be modified independent with mobility, bed mobility and performing transfers. The 
enrollee has full motor strength in the lower extremities and essentially normal motor strength in the upper 
extremities, except for limitation at the left shoulder due to pain. The enrollee has a diagnosis of lumbar 
radiculopathy and does not have lower extremities paralysis. Given the level of mobility and medical 
conditions, a Group 3 power wheelchair would not be indicated. Therefore, the reviewer found that the 
requested Group 3 power 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 a Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound guidance for vascular access (procedure code 
76937) performed on May 5, 2023. 
 
You asked the Plan to pay for an ultrasound guidance for vascular access (procedure code 76937). You say that 
procedure code 76937 is appropriate based on the services performed. The Plan denied your request. The Plan 
says the service at issue in this case are not supported by 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
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 an ultrasound guidance for vascular access (procedure code 
76937). Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
reviewer found that the procedure code billed requires documentation of selected vessel patency; However, no 
documentation of vessel patency using ultrasound guidance was found. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasound guidance for vascular access (procedure code 76937) have not 
been met. Therefore, we decided that the Plan does not have to pay for an ultrasound guidance for vascular 
access (procedure code 76937) performed on May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 device. 
 
You asked the Plan to pre-approve the Life2000 device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 Life2000 device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Life2000 system is not 
medically necessary. The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
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 Life2000 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Life2000 device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152 and 
99153) rendered on January 26, 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 the services are not supported without the required documentation. 
 
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 of the denied codes is: 
 
CPT 99152: 
 
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 
 
CPT 99153: 
 
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; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 
 
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 not supported by the medical records. Our reviewer found that CPT 99152 is not supported. The 
record does not mention moderate sedation. It cannot be verified that this service was performed. 
 
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 moderate sedation services (procedure code 99152 and 99153) rendered on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee scooter/crutch substitute provided on June 20, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness 
of this item. 
 
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 enrollee is non weight bearing in lower extremity secondary to fracture in her foot. The scooter 
is reasonable for an enrollee who can not use crutches. 
 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 a knee scooter/crutch substitute provided on June 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 11, 2023, and July 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for emergency care.  
 
Review of the file shows that you were provided emergency care. You have been asked to pay a $95 
copayment for these services. These services fall within the emergency care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. 
 
The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-
administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, 
we decided that the Plan does not have to pay for the services provided on July 11, 2023, and July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for your 
medical appointments. The Plan denied your request. The Plan says the evidence shows that you have used 
thirty-four (34) one-way trips covered by the plan in 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional trips for your medical appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips (A0100).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on May 30, 2023. 
 
You asked the Plan to pay for the ambulance transportation. You say that this claim should be paid. The Plan 
denied your request. The Plan says this claim was correctly denied as it was billed with modifier -GY. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance claims billed with modifier -GY are 
for noncovered services. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation provided on May 30, 2023.
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 an IRF level of care with trained professionals and 
close medial oversight is the best level of care to decrease the risk of falls, decrease rehospitalization risk, and 
for enrollee success upon discharge. You would like reconsideration based on the records submitted. 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 the enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require, or to currently be able to tolerate, 15 hours per week of 
rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a lower level 
of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at the inpatient behavioral health level of 
care. 
 
You asked the Plan to pre-approve inpatient behavior health services. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the records do not show that the enrollee is 
receiving active treatment. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavior health services. Our 
reviewer says that the request for continued inpatient behavioral health services is not medically necessary. Our 
physician reviewer found the records provided do not indicate it is expected the enrollee would improve in a 
reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation, auditory 
or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to 
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as they did not have 
dangerousness to self or others and was compliant with the treatment. The enrollee was not a danger to herself 
or others and does not have auditory or visual hallucinations. Therefore, the reviewer found that the requested 
continued inpatient behavioral health services are not medically reasonable or 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 inpatient behavior health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued stay at the inpatient behavioral health level of care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the requested trips will exceed your allowed 
limit for the year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient right C2 ganglionectomy (63185, 69990). 
 
You asked the Plan to pre-approve the ganglionectomy. You say that you are in a lot of pain from the back of 
your head. You also say that you have done a lot of injections and had the nerves burnt but not surgery. The 
Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 ganglionectomy. Our reviewer says 
that the requested ganglionectomy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided medical records and review of the current peer-reviewed medical 
literature do not document that treatment with a C2 ganglionectomy has been shown in controlled studies in a 
CMS-approved journal to result in sustained long term health benefits in patients with occipital neuralgia.  
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 ganglionectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an outpatient right C2 ganglionectomy (63185, 69990).