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

 We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2022, to 
March 10, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of diagnosis code A41.89. 
 
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 diagnosis code A41.89. 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 submitted records do not support the billing of diagnosis code A41.89. Our physician 
reviewer found the enrollee presented to the emergency department (ED) on March 7, 2022 with weakness and 
confusion. On exam in the ED, provider documentation noted the enrollee was alert and in no acute distress 
and with non-labored respirations. The history and physical examination noted the enrollee was alert and 
oriented times three, in no acute distress, and with unlabored respiratory effort. The enrollee was initially 
hypotensive; however, mean arterial pressure (MAP) values improved to greater than 70 after initial 
intravenous (IV) fluid administration. There is no clinical or laboratory evidence of sepsis; therefore, diagnosis 
code A41.89 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 7, 2022, to March 10, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 5, 2022, 
to April 10, 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 
enrollee met the criteria for acute kidney injury. The Plan denied your request. The Plan says there is 
insufficient evidence to validate the diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.9, defined as acute kidney failure unspecified. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the hospital after a syncope 
episode with a fall at home. The enrollee was found to have syncope due to bradycardia and was admitted for 
inpatient care. There was no clinical or laboratory evidence of acute kidney injury. The documentation stated 
acute kidney injury on chronic kidney disease stage 2. The enrollees following creatinine was 1.02. The 
enrollee had no baseline creatinine documented. The enrollees creatinine dropped to 1 and was last recorded 
with a creatinine of 1.19. The review has determined that the documentation did not support the billed 
diagnosis code, N17.9. 
 
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 the inpatient hospital services provided from April 5, 2022, to April 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on January 9, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the anesthesia services provided on June 17, 2022.
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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. You say the skilled nursing facility will not provide the level of rehabilitation 
you require to achieve complete independence. The Plan denied your request. The Plan says the IRF services 
requested do 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, rehabilitation and medical needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While you may benefit 
from physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity and 
alternate setting such as 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve L3 percutaneous vertebral augmentation. You say that you are in pain which 
affects your ability to do normal activities. The Plan denied your request. The Plan says this 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 L3 percutaneous vertebral 
augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation of a trial of bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve L3 percutaneous vertebral augmentation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Infed and Venofer before it will approve 
Injectafer. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Injectafer. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not show that 
these drugs would likely be less effective and/or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not show any acute clinical status change, change in medication management or other 
complex treatment in which further skilled nursing would be required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
15, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0998 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code A0998. 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 A0998 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0998 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A0998 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A0998 billed for date of service October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network (OON) 
infectious disease specialist. 
 
You asked the Plan to pre-approve the continuation of care with an OON infectious disease specialist. You say 
that you have been a patient of this OON provider for over 6 years and would like to continue care with him. 
The Plan denied your request. The Plan says you can transition care for your HIV infection to the in-network 
provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
infectious disease specialist. Our reviewer says that the criteria for coverage of OON care have not been met. 
Our physician reviewer found there is nothing unique about the enrollee's condition that would make it 
medically necessary to continue care with the OON provider. The Plan has shown that they have in-network 
specialist who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of your condition. Your medical management and follow-up care can be safely 
transitioned to an in-network infectious disease specialist. 
 
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 continuation of care with an OON infectious disease specialist have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care with an 
out-of-network (OON) infectious disease specialist.
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 LTACH can better assist you. The 
Plan denied your request. The Plan says LTACH services are 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
 The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visits provided on October 18, 2022, and 
November 17, 2022, by an OON provider. 
 
You asked the Plan to pay for the psychotherapy visits. You say that you disagree with the denial of these 
claims. The Plan denied your request. The Plan says that these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you may receive all plan covered services from non-network providers, but must obtain prior 
authorization before seeking care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy visits provided on October 18, 
2022, and November 17, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a total hip replacement and 
rehabilitation services have been requested by their provider. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device and a cold/hot fluid bottle 
provided on July 19, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and a cold/hot fluid bottle. You say that these 
items were medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules say that for equipment to 
be covered, it must primarily serve a medical purpose. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The cold/hot fluid bottle in this appeal does not serve a 
purpose that is primarily medical in nature. This item is available to the general public and would be helpful 
even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device and a cold/hot fluid bottle provided on July 19, 2022.