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

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; sacral nerve (transforaminal placement) including image guidance, if performed (64561) and 
lead, neurostimulator (implantable) (C1778). 
 
You asked the Plan to pre-approve a permanent sacral nerve stimulator implant. You say that the requested 
device is medically necessary due to the enrollee having an overactive bladder. The Plan denied your request. 
The Plan says it was determined that the enrollee does not meet the criteria for a permanent sacral nerve 
stimulator. 
 
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 a permanent sacral nerve stimulator 
implant. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has an overactive bladder and painful bladder 
syndrome. She could not tolerate myrbetriq or trospium. She underwent Axonics PNE from June 12, 2023, to 
June 16, 2023. The enrollee does not meet the criteria for a permanent sacral nerve stimulator. The coverage 
criteria require that the enrollee must have had a successful test stimulation in order to support subsequent 
implantation. Before an enrollee is eligible for permanent implantation, she must demonstrate a 50% or greater 
improvement through test stimulation. Improvement as measured through voiding diaries. In this case, the 
enrollee did not have 50% or greater improvement during the PNE trial. 
 
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 permanent sacral nerve stimulator implant have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode 
array; sacral nerve (transforaminal placement) including image guidance, if performed (64561) and lead, 
neurostimulator (implantable) (C1778).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) billed for 
date of service December 6, 2022.  
 
You asked the Plan to pay for the unlisted molecular pathology procedure . You say that the records provided 
support the services as billed.  The Plan denied your request. The Plan says the billed code is not supported.  
 
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 81479 is unlisted molecular pathology procedure. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the unlisted molecular pathology procedure. Our reviewer 
says that the criteria for coverage have not been met.  Our reviewer found code 81479 is reported when no 
other code is available to report. The documentation does not support an unlisted procedure code, as the 
laboratory report describes Targeted genomic sequence analysis panel.  A more appropriate code would be 
reported for this documented service. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted molecular pathology procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) billed for date 
of service December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 14, 2022, to 
February 22, 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 
billed diagnosis code, J96.21, is supported in the record.  The Plan denied your request. The Plan says there is 
not sufficient documentation to clinically validate the diagnosis of J96.21.  
 
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, J96.21 defined as acute 
and chronic 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 the criteria for coverage have 
not been met.  Our physician reviewer found the enrollee was not hypoxic, or significantly labored in her 
breathing. Physician diagnoses require documentation in the record supporting the diagnosis. Tachypnea alone 
is insufficient criteria for acute respiratory failure.  
 
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 February 14, 2022, to February 22, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that Keytruda is not FDA approved for the 
enrollee's diagnosis. The enrollee has progression on programmed death-ligand 1 (PD-L1) treatment and the re- 
 biopsy shows PD-L1 expression less than 1%. Not recommended to continue Keytruda as second line with 
other systemic chemotherapy when progressed on Keytruda as recommended in the drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of congenital 
interatrial communication with implant (93580). 
 
You asked the Plan to pre-approve a patent foramen ovale (PFO). You say that the enrollee needs a PFO 
closure to decrease the risk of another stroke. The Plan denied your request. The Plan says a review of the 
current medical literature indicates that percutaneous PFO closure may be more effective for preventing 
recurrent ischemic stroke than antiplatelet therapy alone for highly selected enrollees who have an embolic-
appearing cryptogenic ischemic stroke and a PFO. The request is not medically necessary. 
 
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 a patent foramen ovale (PFO). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of recurrent thalamic strokes. The enrollee has no 
evidence of ischemic or thromboembolic strokes and has echocardiographic evidence of a small PFO with right 
to left shunting. As such, guidelines would not support the need for a PFO closure device. In summary, there is 
insufficient documentation to support the medical necessity for the requested PFO closure in this enrollee's 
clinical 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 a patent foramen ovale (PFO) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous transcatheter closure of congenital interatrial communication 
with implant (93580).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has impaired ability and strength 
training due to a fall they had because of weakness and balance issues. The Plan denied your request. The Plan 
says the coverage criteria has 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 that the enrollee does not have complex nursing or rehabilitation needs. 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-
minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says that the records do not 
show that the enrollee meets criteria for approval of this service. Your dentist plans extraction of your tooth but 
there is no indication that you have osteoradionecrosis on exam or on x-ray.  
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was diagnosed with tongue cancer in 2015 and was treated 
with external beam radiation. The enrollee has been diagnosed with osteoradionecrosis of the mandible and 
maxilla. The enrollee has a dry mouth and gradually worsening dental decay. It has been determined that tooth 
#31 is decayed and non-restorable. Extraction is planned. Due to the significant amount of external beam 
radiation the enrollee previously received, he was referred for pre and post extraction hyperbaric oxygen 
treatments. Per NCD 20.29, coverage for HBOT is provided in the setting of osteoradionecrosis as an adjunct 
to conventional treatment. In this case, the planned conventional treatment is extraction of tooth #31. However, 
given the high risk of complications in the setting of osteoradionecrosis, HBOT has been ordered to reduce the 
risk. HBOT is medically necessary 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 hyperbaric oxygen therapy (HBOT) have been met. Therefore, we decided that 
the Plan has to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the accessories are medically 
necessary for the enrollee. The Plan denied your request. The Plan says upgraded electronics (electronic 
connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when 
there is a medical need to control power options though the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has L hemiplegia. The plan has approved a group 3 power wheelchair 
with multiple power options. The enrollee is able to feed herself and groom herself. Per SSA 1862 (a)1(A) as 
enrollee has adequate strength to manage standard power drives. Not medically necessary to meet the enrollee's 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 1, 2022, to 
September 7, 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 
records provided support the services as billed.  The Plan denied your request. The Plan says the billed DRG 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 principal diagnosis code A41.52, defined as Sepsis 
due to Pseudomonas. 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 criteria for coverage have not been met.  Our 
physician reviewer found the enrollee presented to the hospital with pneumonia. She had a fever and elevated 
white blood cell (WBC) count and an elevated pulse. Systemic inflammatory response syndrome (SIRS) 
criteria were met. She did not have evidence of immune dysfunction associated with infection, the international 
consensus definition of sepsis. There was no impaired cardiac, renal, liver, pulmonary, or hematologic 
dysfunction. She did have some lethargy, which is a common accompaniment of infection among elders. The 
international consensus criteria for sepsis were not present.   
 
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 September 1, 2022, to September 7, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve definitive drug testing (G0482) provided on October 11, 
2022. 
 
You asked the Plan to pre-approve the definitive drug testing. You say that these services were medically 
necessary and were reported correctly.  The Plan denied your request. The Plan says the number of classes 
tested in this case were not medically necessary. In all cases, the number of drug classes tested should reflect 
only those likely to be present based on the medical history, current clinical presentation and the illicit drugs 
that are in common use.  
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the definitive drug testing. Our 
reviewer says that the definitive drug testing is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the diagnosis is chronic pain of neck, right leg and lower back and medication 
management of long term (current) drug therapy. Medications included Morphine extended release, 
Hydromorphone, and butalbital-APAP-Caffeine. The medical record sent by the provider showed presumptive 
screening test results which were consistent with prescription medications, dosing schedules, or history and 
expected results. There was sufficient information to manage the enrollee without definitive testing. The review 
has determined that the number of drug classes tested in this case was not 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 the definitive drug testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve definitive drug testing (G0482) provided on October 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's health is at severe risk without prompt 
physical therapy. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is recommended to repair the battery of the group 2 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found that you have a 
power wheelchair which is functional but requires a battery replacement. Replacement of the battery over a 
new scooter is reasonable and necessary. The record does not support a requirement for a scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.