Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), and 
related items and accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2331, E2361, E2377, E2607, 
E2620, K0040, and K0108). 
 
You asked the Plan to pre-approve the group 3 standard power wheelchair with multiple power options and 
related accessories. You say that the enrollee needs a group 3 power wheelchair with multiple seating functions 
to keep them active in their home. You also say that without this power chair, the enrollee will soon be 
confined to their bed or recliner. The Plan denied your request. The Plan says the enrollee does not have 
medical need for multiple power options included with K0861 group 3 power wheelchair. The Plan also says 
that the electronic connection, harness, and expandable controller cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that power seating systems and components are only 
covered when certain criteria have been met and when medically 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 group 3 standard power wheelchair 
with multiple power options and related accessories. Our reviewer says that the criteria for coverage have not 
been met. Our physician reviewer found, although provided records document a prior history of a pressure 
ulcer, they do not support the enrollee is unable to perform a functional weight shift. She walks short distances 
with a walker and the face-to-face physician evaluation reports no upper extremity weakness. The records also 
do not document the enrollee performs bladder self-catheterization or that the enrollee has increased muscle 
tone or spasticity to meet criteria for the power tilt and/or recline and thus the multiple power option base. As 
the requested wheelchair base does not meet Medicare coverage criteria, the requested accessories are also not 
covered. 
 
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 group 3 standard power wheelchair with multiple power options and related 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
standard power wheelchair with multiple power option, sling/solid seat/back, patient weight capacity up to and 
including 300 pounds (K0861), and related items and accessories (E0955, E1007, E1012, E1028, E2311, 
E2313, E2331, E2361, E2377, E2607, E2620, K0040, and K0108).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 9, 2023, to  
April 24, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of the 
consultations in the patient's medical record. There was not documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 9, 2023, to 
April 24, 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 the enrollee needs an IRF stay to regain as much 
function and strength as possible, while also having the proper physician management and 24/7 nursing care. 
You say that a lower level of care of any kind is not enough to adequately help the enrollee return to their prior 
level of function and improve their quality of life. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in an alternate and low intensity setting such as a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says there remains a dearth of randomized, 
blinded clinical studies examining the long-term clinical outcomes to establish the value of CardioMEMS. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet 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 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 
was admitted for pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does 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 and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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. Medically necessary care can be 
provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are having difficulty walking and are in need of 
inpatient rehabilitation therapy. The Plan denied your request. The Plan says the notes do not show that your 
care specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not 
show that you have complex care needs that require a coordinated team approach; the notes do not show that 
you must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-
care functioning.  
 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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation 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, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation does not support that you 
would meet criteria for admission to an IRF.  There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status.  You can receive further 
services 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was crucial to treating the enrollee's 
condition. The Plan denied your request. The Plan says that the testing was incorrectly coded. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The Local Coverage Determination and Article, L38814 and A58996, 
the Plan used in their decision to deny services is not applicable in this case. The records do not show that the 
enrollee received minimal residual disease testing for cancer. The records do show that the enrollee received T-
Cell receptor Beta and Gamma molecular diagnostic tests. The tests provided did demonstrate analytical and 
clinical validity, and clinical utility at a level that meets the Medicare reasonable and necessary requirement. 
The claim does show that the required unique identifier was reported. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for the lab testing billed for date of service May 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed for January 30, 2023, with 
procedure code 0315U. 
 
You asked the Plan to pay for procedure code 0315U. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0315U 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
for January 30, 2023, with procedure code 0315U.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care and services provided from November 10, 2022, 
to November 18, 2022. 
 
You asked the Plan to pay for inpatient care. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial cites a rule that does not support or address the 
Plan's denial reason. The Plan has not provided medical records for the inpatient stay at issue. It is the Plan's 
responsibility to support its denial with evidence. In this case, the Plan's denial is not supported. Based on the 
available case record, we are unable to confirm the Plan's denial rationale, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for inpatient hospital care and services provided from November 
10, 2022, to November 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service June 18, 
2023, to July 15, 2023. 
 
  You asked the Plan to pay for procedure code S9328. You say that the enrollee was referred to this provider to 
avoid any complications and the authorization approved codes S9328, 99601, 99602, 62368, and 62369. You 
say that the claim should be processed for payment. 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 dates of service June 18, 2023, to July 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88381 and 81479 billed for date of 
service June 6, 2023. 
 
You asked the Plan to pay for procedure code(s) 88360, 88381 and 81479. You say that these services were 
necessary and are supported in the medical records. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. In addition, the enrollee was in a Part A covered stay at the time of services. This means that the 
laboratory service billed with code 81479 would be paid to the facility under arrangements to the laboratory. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88360, 88381 and 
81479 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360, 88381 and 81479 billed for date of service June 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 15, 2022, to 
October 26, 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 
diagnosis code A41.51 (Sepsis due to Escherichia coli) was accurately reported and billed with the appropriate 
DRG. The Plan denied your request. The Plan says that the medical records did not have sufficient 
documentation to clinically validate the diagnosis of A41.51, (Sepsis due to Escherichia coli). Therefore, 
diagnosis code A41.51 is not supported. 
 
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 A41.51 (Sepsis due to Escherichia coli). 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 physician reviewer found the documentation indicates that the patient was admitted with 
pyelnephritis (past medical history significant for renal calculi, chronic obstructive pulmonary disease (COPD) 
on home oxygen). The patient was hemodynamically stable and on supplemental oxygen (86% on room air and 
95% on supplemental oxygen). She was found to have an obstructing kidney stone. Post-procedurally, the 
patient had acute on chronic respiratory failure. After further review, it is determined that the patients acute on 
chronic respiratory failure is a result of anethesia, intubation, COPD, lung fibrosis and pneumonia after her 
operation.  
 
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 October 15, 2022, to October 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.