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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient would benefit from a short term IRF to 
improve their functional mobility, activities of daily living, and gait to reduce acute care hospital admission and 
caregiver burden. The Plan denied your request. The Plan says the criteria for admission to the Acute Inpatient 
Rehabilitation setting have not been met. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
date of service March 31, 2023. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the documentation does not corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Outpatient 
intravenous insulin therapy, billed with codes 96365 and 96366, is not covered under Medicare. The records do 
not show that the refilling and maintenance of a portable pump, billed with code 96521, was provided. We find 
that there is a more accurate code to describe the injection services billed with code J1817.  Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
date of service March 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 You asked the Plan to pre-approve Avastin. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Avastin. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the appropriate 
level of care for the enrollee. You say that the enrollee is medically stable to be transferred to an LTACH. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is currently receiving all indicated care in the acute care hospital. 
There are also no specific treatments that the enrollee would receive at the LTACH that are not currently 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) (E0483).  
 
You asked the Plan to pre-approve a HFCWOD. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a 
covered neuromuscular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You also say that, in their current condition, the enrollee's needs cannot be adequately 
cared for at a skilled nursing facility or any other lower level of care. The Plan denied your request. The Plan 
says admission to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72040, 70100, 74230, 99204) provided 
on January 31, 2023. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 72040, 70100, 74230, & 99204 are not supported in the medical record. Specifically, 
the claim was billed with place of service 11, however the records show the service was provided in a mobile 
setting at a skilled nursing facility, not an outpatient or office setting. Based on this information, we decided 
that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the 
Plan does not have to pay for radiology services (72040, 70100, 74230, 99204) provided on January 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service March 1, 
2023, to March 15, 2023. You asked the Plan to pay for the billed services. You say that the claim should not be denied due to the late 
submission. The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 1, 2023. The NOA was not received by the Plan until April 6, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of 
service March 1, 2023, to March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on March 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 30, 2022, to September 
9, 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 
patient met criteria for the billing of diagnosis J15.6 (pneumonia due to other gram-negative bacteria). The Plan 
denied your request. The Plan says that the billed diagnosis of J15.6 (pneumonia due to other gram-negative 
bacteria) is not clinically validated in the medical record. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a secondary diagnosis of J15.6 (pneumonia due to 
other gram-negative bacteria). 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 diagnosis of J15.6 (pneumonia due to 
other gram-negative bacteria) is supported by the medical record. Our physician reviewer found although 
computed tomography of the chest did not show an infiltrate, it was not a perfect protocol and there were 
infiltrates of the x-ray with treatment for bacterial pneumonia. As a result, the billing of this diagnosis was 
justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on August 30, 2022, to September 9, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 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 code 99232 billed for date of service March 9, 2023. 
 
You asked the Plan to pay for code 99232. You say that this service was medically necessary and rendered by 
your provider. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 43281 
provided on March 8, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99232 billed for date of service 
March 9, 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 documentation supports the necessity 
for the requested therapy, and indicates the patient has tried and failed a respiratory assist device with bi-level 
pressure capability (E0470). The Plan denied your request. The Plan says the request for continued use of a 
non-invasive ventilator (NIV) is not medically reasonable and 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. 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 a home ventilator. Our reviewer says 
that the patient does not meet the criteria for coverage. Our physician reviewer found the documentation does 
not support that the patient has significant hypoxia or significant hypercarbia that would require the requested 
NIV at home. Our reviewer also found the documentation does not support that the patient is complaint with 
treatment ordered by their medical provider. 
 
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 pre-approve sacroiliac joint injections and procedures. 
 
You asked the Plan to pre-approve sacroiliac joint injections and procedures. You say that it is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval.  
The Plan follows Medicare rules. Medicare rules say that SIJI may be 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 sacroiliac joint injections and 
procedures. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
review has determined that the enrollee does not meet the coverage indications for this procedure. The enrollee 
does not meet any of the limitations/exclusions for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injections and procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures.
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 in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. 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 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. 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 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 the 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065). 
 
You asked the Plan to pre-approve a breath hydrogen or methane test. You say that you cannot keep food down 
and have already done a lot of testing. The Plan denied your request. The Plan says the criteria were not met. 
 
The Plan follows Medicare rules. Medicare rules say that a lactulose breath hydrogen test for diagnosing small 
bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. 
 
 
 
 
 
 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 breath hydrogen or methane test. Our 
reviewer says that the coverage criteria as provided are not met in this case. Our physician reviewer found you 
have complaints of intermittent bloating and right lower quadrant abdominal pain responsive to a low 
fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet. Our reviewer also found that 
your provider characterizes the complaint as "abdominal gaseous distension" and on July 10, 2023, advised 
testing for SIBO (small intestinal bacterial overgrowth). 
 
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 breath hydrogen or methane test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a breath hydrogen or methane test (91065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 3, 2023.