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 from January 11, 
2022, through January 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
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 these services. 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 presented to the emergency department (ED) with weakness for several days 
and decreased oral intake and nausea. The workup revealed hyperkalemia, acute on chronic renal insufficiency, 
lactic acid elevation, COVID-19 positive, and pneumonia on imaging which was treated with fluids, 
antibiotics, zofran, and oxygen support. On evaluation, the enrollee had stable vital signs including an oxygen 
saturation level of 92-93% on room air, was not in respiratory distress, was responding to initial treatment, and 
did not require invasive or complex care. The enrollee was not expected to require hospital care that would 
likely cross two midnights. An observation status would have been appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from January 11, 2022, through January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on December 7, 2022. 
 
You asked the Plan to pay for critical care services (99291). You say that the medical documentation 
substantiates the service rendered and the claim should be reprocessed. The Plan denied your request. The Plan 
says the documentation submitted does not support a critical care visit of 30 to 74 minutes. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
document the time spent on the critical care visit as required by the procedure code billed. Based on this 
information, we decided that Medicare rules for coverage of critical care services (99291) have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on 
December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43246-82 billed for date of service March 15, 
2023. 
 You asked the Plan to pay for the billed services. You say that both physicians were necessary for this 
procedure. The Plan denied your request. The Plan says there is no reference to an assistant at surgery. 
 
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 
0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is 
submitted to establish medical necessity.  
 
We looked at the file, and Medicare rules. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 43246-82. The Medicare Fee Schedule Database contains a surgical 
indicator of 0 for this procedure. The records provided do not identify the role the assistant played in the 
procedure at issue. The records do not show an assistant was needed for this procedure. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 43246-82 billed for date of service March 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (80307, G0483) provided on November 30, 2022. 
 
You asked the Plan to pay for drug testing. 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. In this case, the Plan's denial rationale appears to be based on a rule that does not 
pertain to the services at issue. It is the Plan's responsibility to support its denial with valid citations of the rules 
and with evidence. In this case, the Plan's denial has not been supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for drug testing services (80307, G0483) provided on November 
30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 13, 
2022, to April 15, 2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient stay was medically 
necessary at the acute level of care. You also say that you are requesting that the denial be overturned and the 
payment for inpatient treatment rendered appropriately as per the expected reimbursement. The Plan denied 
your request. The Plan says the information does not support that criterion were met for inpatient 
hospitalization. The Plan also says the enrollee had no documentation of hemodynamic instability, sepsis, 
bacteremia, or need for intravenous antibiotics. 
 
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 the 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 the enrollee presented to the emergency department with fever, chills, and 
body aches. Examination revealed the enrollee to be alert, no respiratory distress but with a temperature of 102 
and lower extremity edema. Our reviewer found that workup ruled out infection, vitals remained stable, 
doppler was negative for deep vein thrombosis, and imaging was without acute abnormalities. The enrollee was 
given intravenous fluids, antibiotics, and Zofran. Our physician reviewer also found that based on the low 
complexity and low severity of the presentation of this enrollee, it was not expected that they would require 
hospital care that would likely cross 2 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 the 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 April 13, 2022, to April 15, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 24, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 24, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
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 psychiatric care from July 24, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 24, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond July 24, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
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 psychiatric care from July 24, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 24, 2023, 
forward.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from July 25, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services from July 25, 2023, forward. You say 
that the services at issue were medically necessary. The Plan denied your request. The Plan says that the 
services at issue were not medically necessary. 
 
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 psychiatric hospital services 
from July 25, 2023, forward. Our reviewer says that the enrollee meets the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of July 25, 2023, forward. Our physician reviewer 
found based upon review the records provided for the admission of this enrollee does meet criteria for acute 
inpatient mental health treatment as this enrollee was shown to be a danger to himself but not others, with 
auditory but no visual hallucinations. It did appear that active treatment was taking place. It did appear that the 
services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. 
 
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 psychiatric hospital services from July 25, 2023, forward have been 
met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from July 25, 2023, 
forward.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 21, 2022, to 
September 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 21, 2022, to 
September 19, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic 
kidney disease. She has not tried and failed the Plan's required drugs, Retacrit or Procrit. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Aranesp is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801 and 87150-59 billed for date of 
service December 19, 2022. 
 
You asked the Plan to pay for procedure codes 87801 and 87150-59. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
are not supported in the medical record. 
 
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 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 procedure codes 87801 and 87150-59. Our reviewer says that 
these codes are not supported as billed. Our reviewer found the reported units of CPT code 87801 are not 
supported. Three units were billed; however, the record has results for 2 organisms, which equals 2 units. In 
addition, code 87150 is not supported by the medical record. The record does not specify which organisms 
were tested that would be considered "multiple" and were not included in one of the already approved CPT 
codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87801 and 87150-59 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87801 and 87150-59 billed for date of service December 
19, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. The enrollees condition is complex and fragile, and there 
is every reason to expect that the enrollee will participate in and benefit from services to include at minimum 
physical therapy, occupational therapy, physician management of the enrollee ongoing infection disease, 
oncological, and cardiovascular comorbidities, as well as case manager coordination of any additional services 
that might be needed to ensure a sustainable return home.  Therefore, the requested inpatient rehab facility 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says that although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing their basic daily activities. The enrollee cannot perform pressure relief 
independently due to upper extremity weakness and requires a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. Our reviewer found that the enrollee requires power elevating leg rests 
for positioning of their lower extremities and lower extremity spasticity and edema. The complexity of the 
enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our 
physician reviewer also found that the expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options via a joystick. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planning-four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planning. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the code your dentist sent must have at least four 
teeth in the same part of the mouth that need treatment. The x-rays your dentist sent do not show you have four 
teeth that need treatment. 
 
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. The Plan covers periodontal 
scaling and root planning when the services are medically necessary and reasonable. 
 
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 periodontal scaling and root planning. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a review of the 
documentation indicates that periodontal pockets of 5-8mm are present in these quadrants. Including the 
implants, there are four or more teeth in these quadrants needing treatment. Therefore, periodontal scaling and 
root planing is medically reasonable and necessary to treat the enrollees periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planning have been met. Therefore, we decided 
that the Plan has to pre-approve periodontal scaling and root planning-four or more teeth per quadrant (D4341).  
 
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.