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

 
We decided that the Plan does not have to pay for the anesthesia services (01924) provided on January 24, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made under the fee schedule for 
anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. Payment is 
determined based on the base unit of the anesthesia procedure with the highest base unit value and time units 
based on the actual anesthesia time of the multiple procedures.  
 
We looked at the file and Medicare rules. In this case, anesthesia code 01270 was billed and paid for the same 
date of service. As code 01270 has the higher base unit value, code 01924 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services (01924) provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (A6549) and a gradient 
compression wrap (A6545). 
 
You asked the Plan to pre-approve the compression stockings and compression wrap. 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. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. The rules say that compression stockings described by code A6549 are noncovered 
because they do not meet the statutory definition of a surgical dressing. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Although the gradient compression wrap may be appropriate, it does not fall into a covered benefit category 
and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-
approve gradient compression stockings (A6549) and a gradient compression wrap (A6545).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have the required diagnosis of nonmyeloid malignancy.  
 
The Plan follows Medicare rules. Medicare rules say that Neulasta is covered for the conditions described in 
the 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 Neulasta. Our reviewer says that the 
requested use of Neulasta is not supported. Our physician reviewer found there is no demonstrated role for 
routine, prophylactic treatment with myeloid growth factors in patients with myelodysplastic syndrome (MDS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0748). 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that you just had multi-level 
spinal fusion surgery. You also say that you would like this to be overturned so you can get this item to help 
your healing. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 electrical bone growth stimulator. 
Our reviewer says that the requested electrical bone growth stimulator is not medically necessary. Our 
physician reviewer found the provided documentation indicates that the enrollee had a single level fusion. The 
reviewer also found that it has not been nine months since the fusion was performed. Therefore, the reviewer 
found that the requested service is not medically 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 an electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone growth stimulator (E0748).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Notal Vision System. 
 
You asked the Plan to pre-approve an eye surgery. You say that you have problems with light-sensing part of 
your eve. The Plan denied your request. The Plan says this device has not shown to improve outcomes 
compared to standard methods of monitoring. 
 
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 an eye surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical criteria for this service have not been met. 
 
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 eye surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Notal Vision System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0275T) provided on January 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without a valid clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service on or 
after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in 
clinical trials/studies/registries, or under Coverage with Evidence Development (CED).  
 
We looked at the file and Medicare rules. The claim in this case was billed without a valid clinical trial number. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services (0275T) provided on January 12, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496.  
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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. The records do 
not support that he requires treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressing (A6222) provided on March 2, 2023. 
 
You asked the Plan to pay for the dressing room. The Plan denied your request. The Plan says the dressing was 
provided too soon. 
 
The Plan must follow Medicare rules. Medicare rules say that for delivery of refills, the supplier must deliver 
the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. 
 
We looked at the file and Medicare rules. The records show that 30 units of code A6222 was provided on February 16, 2023, which is a 30-day supply. The requested shipment was delivered on March 3, 2023, which 
is sooner than 10 calendar days prior to the end of usage for the delivery made on February 16, 2023. Based on 
this information, we decided that Medicare rules for coverage of the dressing room have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound dressing (A6222) provided on March 2, 
2023.
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 a power scooter. The Plan denied your request. The Plan says Medicare's 
medical necessity criteria have not been met. 
 
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 a power scooter. Our reviewer says that 
a power scooter is not medically reasonable and necessary for you. Our physician reviewer found the 
documentation available for review does not support that you require a power mobility device to accomplish 
mobility related self-care tasks in the home. Our reviewer also found that there is no indication you are unable 
to use an alternative assistive device. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 16, 2021, to 
October 23, 2021, 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 N17.9. 
 
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. 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 N17.9. Our physician reviewer found the 
enrollee presented with loss of consciousness and was found to have transaminitis on testing, tachycardia, 
elevated respiratory rate with normal oxygenation, and leukocytosis. She was diagnosed with rhabdomyolysis 
and started on fluids. The records do not show increases in creatinine of 1.5 more than baseline or 0.3 mg/dL 
over 48 hours or significant enough oliguria to meet the criteria for kidney failure. Her kidney function was 
stable throughout the admission. The records do not support the billing of 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 inpatient hospital services provided on October 16, 2021, to October 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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 will benefit from acute inpatient 
rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee attempted to receive treatment from a 
different facility but was denied. The Plan denied your request. The Plan says the enrollee no longer requires 
skilled services on a daily inpatient basis. 
 
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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric office visits and services to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve psychiatric services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
psychiatric office visits and services to be provided by an out-of-network (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 meets full IRF criteria. You also say the 
enrollee requires intensive inpatient rehabilitation with daily physician management, continuous specialized 
rehabilitation nursing, and intensive therapies to optimize mobility and strength while ensuring the restoration 
of functional status for a safe and sustainable discharge. 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission to allow the enrollee to have the intense physical therapy and care they need and deserve.  
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.