Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that epidural steroid injections are 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injections do 
not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 epidural steroid injections. Our 
reviewer says that the requested epidural steroid injections are not considered medically necessary in this case. 
Our physician reviewer found that in this case, the enrollee has low back pain radiating to the left lower 
extremity. There has not been a course of physician-directed conservative care prior to the requested injection.  
In addition, the patient has failed multiple injections to date. The review has determined that the requested 
epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Iluvien (J7313). 
 
You asked the Plan to pre-approve Iluvien. You say that Iluvien is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Iluvien has been prescribed for an off-label, not medically accepted 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Iluvien. Our reviewer says that Iluvien 
is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a 
diagnosis of Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 
edema with documented increased intraocular pressure. The FDA has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Iluvien have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Iluvien (J7313).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 have complex or intensive rehabilitation needs. The enrollee has 
basic post-acute deconditioned rehabilitation needs. The enrollee has low capacity for intensive rehabilitation. 
No indication for frequent physiatry oversight. The IRF care 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
November 10, 2022.  
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says the number of units of 88342 billed exceeds 
the maximum allowed, and as this code is denied, 88341 has not been billed with an appropriately billed 
primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that submitted claims in 
which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is 
evidence justifying the excess units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. In addition, we have confirmed 
that code 88341 is an add-on code and has not been billed with an appropriately reported primary procedure 
code. Based on the claim submitted, Medicare billing criteria have also not been met for code 88341. 
Therefore, we decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date 
of service November 10, 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 provided records document that the home ventilator is being requested for use in intelligent volume assured 
pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records document trial of 
BiPAP, but the records do not specify trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 2, 
2023, to March 4, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says that the enrollee did not have an infection or a fever. 
 
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 the enrollee did not have signs or symptoms of an emergent vascular blockage or 
infection to demand inpatient services that were expected to cross two midnights.  
 
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 from March 2, 2023, to March 4, 2023.
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 the enrollee failed bilevel positive airway 
pressure (BiPAP) treatment.  The Plan denied your request. The Plan says the requested device 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 the device is not medically necessary. Our physician reviewer found that the provided records in this case 
document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. The 
provided records document that the home ventilator is being requested for use in intelligent volume assured 
pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with 
average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for intraoperative neuromonitoring (IOM) provided on August 4, 2022. 
 
You asked the Plan to pay for IOM. You say that the surgeon determined that these services were medically 
necessary. The Plan denied your request. The Plan says that this does not meet criteria for coverage. 
 The Plan follows Medicare rules. Medicare rules state that intraoperative neuromonitoring (IOM) is covered for 
certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for IOM. Our reviewer says that these services 
meet criteria for payment. Our physician reviewer found the enrollee underwent intraoperative 
neuromonitoring on August 4, 2022 during surgery for thoracic spinal stenosis. Per the operative report the 
enrollee underwent T9-L3 fusion with allograft, local bone graft and expedium instrumentation. These IOM 
services meet the indications for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IOM have been met. Therefore, we decided that the Plan has to pay for 
intraoperative neuromonitoring (IOM) provided on August 4, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral blepharoplasty; upper eyelid (15823). 
 
You asked the Plan to pre-approve bilateral blepharoplasty. You say that your eyelids are drooping. You say 
that it bothers you all the time. You also say that it makes your eyes tear a little. The Plan denied your request. 
The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 bilateral blepharoplasty. Our reviewer 
says that the bilateral blepharoplasty is not medically necessary. Our reviewer found the provided 
documentation supports that the marginal reflex distance (MRD) is not less than 2.0 mm. The reviewer found 
that the confrontation visual fields document full fields in both eyes. The reviewer found that the visual field testing provided are unreliable due to high fixation losses and false negative errors. Therefore, the reviewer 
found that the requested bilateral blepharoplasty 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 bilateral blepharoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral blepharoplasty; upper eyelid (15823).
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 the enrollee's provider indicates that BiPAP 
is insufficient for the enrollee due to the severity of their condition. The Plan denied your request. The Plan 
says the requested 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 the requested home ventilator is not medically necessary. Our physician reviewer found the provided 
documentation support a diagnosis of chronic obstructive pulmonary disease (COPD). The reviewer found that 
the enrollee' arterial blood gas (ABG) during the hospitalization was consistent with mild acute on chronic 
hypercarbic respiratory failure. The reviewer found that there are no pulmonary function tests to confirm 
airways obstruction or assess severity.  There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease.  There is no ABG done while stable to document chronic carbon dioxide (CO2) retention. Therefore, 
the reviewer found that the requested ventilator 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2022, to 
March 20, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
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 codes A41.9, described as 
Sepsis, unspecified organism, and J96.01, described as acute respiratory failure with hypoxia. 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 documentation does not support the billed codes. Our physician reviewer found the 
enrollee presented with abdominal pain. She was found to have acute cholecystitis and underwent gallbladder 
removal. While the enrollee had a perioperative fever, there is no evidence that she had sepsis (hypotension, 
hypoperfusion, organ dysfunction). While the enrollee received treatment for her asthma, there is no evidence 
that she had respiratory failure. As such, the billing of A41.9 and J96.01 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 March 15, 2022, to March 20, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is 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. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this drug. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules 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 pre-approve Omeprazole.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210), 
periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record shows your benefit for the periodic oral evaluation and prophylaxis was exhausted on date of service June 8, 
2022. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic 
images (D0210), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 1, 2021, to 
December 7, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 N17.9, described as acute 
kidney failure, unspecified. 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 documentation does not support the billed 
code. Our physician reviewer found the enrollee presented with altered mental status.  He was found to have 
worsening renal function, in the form of prerenal azotemia.  The enrollee responded to intravenous fluids and 
does not appear to have had intrinsic renal failure.  As such, the billing of N17.9 does not appear to be 
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 December 1, 2021, to December 7, 2021, at the Diagnosis Related 
Group (DRG) originally billed.