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

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from 
October 26, 2022, to October 31, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you had to go to this 
hospital due to your condition. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network inpatient hospital care.  
 
Due to meeting your out-of-pocket maximum, you have been asked to pay $4,189.71, which is less than the 
standard 50% coinsurance for the inpatient hospital stay. This item/service falls within the inpatient hospital 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay 
provided from October 26, 2022, to October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel surgery (64721). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that you are in constant pain. You say that 
you are not able to perform your job. You also say that you right hand is so bad you cannot hold a brush. The 
Plan denied your request. The Plan says the records do not show attempts to manage your symptoms with 
splinting or a local steroid injection. 
 
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 outpatient surgery. Our reviewer 
says that the requested carpal tunnel surgery is not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation to show a trial and failure of conservative care measures 
has not been provided. The reviewer found there is no indication of any physical therapy, glucocorticosteroid injection, and/or bracing. The reviewer found that there is no compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
carpal tunnel surgery 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 the outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve carpal tunnel surgery (64721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rezum system. 
 
You asked the Plan to pre-approve the Rezum system. You say that the Rezum system is medically necessary. 
The Plan denied your request. The Plan says the Rezum system 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 the Rezum system. Our reviewer says 
that the requested Rezum system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that the enrollees prostate size is 25.5 mL and the Rezum 
procedure is appropriate for men with prostate size of 30- 80 mL.  
 
 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 Rezum system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Rezum system.
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 an IRF admission is necessary for you to return to 
your prior level of function. 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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you 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 you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 24, 2023. 
 
You asked the Plan to pay for injections. You say that you that the patient has established care and wishes to 
continue seeking services for this condition under this physician at this location. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided 
from March 3, 2023, to March 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were told 
there was no copayment for the first 21 days of your stay. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-5 of each inpatient rehabilitation stay. Your contract with the Plan also clearly 
says that you must pay a $0 copayment per day for any additional days of the same inpatient rehabilitation stay. 
 
You have been asked to pay a $300 copayment per day for days 1-5 of the inpatient rehabilitation stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,500  for the inpatient 
rehabilitation stay ($300 copayment per day x 5 days = $1,500). This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient rehabilitation stay provided from March 3, 2023, to March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the enrollee has open wounds that need care. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for HBO therapy. 
 
The Plan follows Medicare rules. Medicare rules state that HBO therapy is covered under certain 
circumstances. 
 
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 HBO therapy. Our reviewer says that 
the enrollee does not meet criteria for HBO therapy. Our physician reviewer found the documentation showed 
improving wound volume with standard wound treatments, but HBO therapy was not documented as having 
been continued after June 30, 2023 as part of this treatment which led to improvement suggesting standard 
therapy alone was helpful which would disqualify the enrollee from additional HBO therapy. Although the 
enrollee has an indication for this therapy, the criteria is not met for continuation of HBO therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on February 23, 2023, billed 
with codes 96365, 96366, 96521, and J1817. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365, 96366, 96521, and J1817 is Intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1-hour, Intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure), refilling and maintenance of portable pump, and Insulin for 
administration through durable medical equipment  (i.e., insulin pump) per 50 units.  
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 Practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the records provided documents that 
Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the 
results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or 
capillary glucose; and/or potassium concentration was performed, which has a more appropriate code to 
describe the service performed. Additionally, OIVIT regimens are not covered nationally by Medicare. 
Therefore codes 96366 and 96365 cannot be verified. There is no documentation that includes a procedure 
report for pump maintenance refill, so procedure code 96521cannot be verified. The medical records provided 
states the Nova R was administered via intravenous treatment, which does not meet the definition described by 
code J1817, therefore this procedure cannot be verified.  
 
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 Practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for Practitioner services provided on February 23, 2023, billed with codes 96365, 
96366, 96521, and J1817.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the negative pressure wound therapy (NPWT) pump provided from 
June 1, 2022, to July 31, 2022. 
 
You asked the Plan to pay for the NPWT pump. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a NPWT is covered when the criteria are met in the 
applicable LCD. 
 
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 NPWT pump. Our reviewer says that the 
requested NPWT pump is medically reasonable and necessary. Our physician reviewer found that the enrollee 
is a 48-year-old female with quadriplegia and related chronic pressure ulcer which had been treated in the past 
with negative pressure wound therapy with benefit. The provided records include documentation of care and 
wound measurements by her doctor, dressing applications, occasional but infrequent wound debridement, and 
discussion of nutritional status. She has an appropriate seat cushion and moisture is being managed. Based on 
the criteria and provided documentation, it appears the patient does meet criteria "A" for a negative pressure 
wound therapy pump as requested.  
 
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 NPWT pump have been met. Therefore, we decided that the Plan has to pay 
for the negative pressure wound therapy (NPWT) pump provided from June 1, 2022, to July 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87481, 87640, 87652, 87798) provided on 
January 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 services. Our reviewer says that the use of codes 87481, 
87640, 87652, and 87798, is not supported by the records provided. Our reviewer found that for code 87481, 
the laboratory report does not include documentation of Candida species, amplified probe technique. The 
laboratory report documents "Organism(s) Detected; No organisms detected". This procedure cannot be 
verified as performed. For code 87640, the laboratory report does not include documentation of Staphylococcus aureus, amplified probe technique. The laboratory report documents "Organism(s) Detected; No organisms 
detected". This procedure cannot be verified as performed. For code 87652, the laboratory report does not 
include documentation of Streptococcus, group A, quantification. The laboratory report documents 
"Organism(s) Detected; No organisms detected". This procedure cannot be verified as performed. For code 
87798, the laboratory report does not include documentation of Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism. The laboratory report 
documents "Organism(s) Detected; No organisms detected". This procedure cannot be verified as performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (87481, 87640, 87652, 87798) provided on January 25, 2023.
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 IRF admission criteria, and their 
ongoing medical care warrants this level of care to achieve a safe and sustainable discharge. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel provided on 
August 3, 2022.  
 
You asked the Plan to pay for the comprehensive pharmacogenetics panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says a comprehensive panel for genotyping of 
genetic variations that may be linked to reduced/enhanced effect or severe side effects of drugs metabolized 
remains unproven as a screening tool.  
 The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the comprehensive pharmacogenetics panel. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
pharmacogenetics panel is not standard of care and not medically 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 the comprehensive pharmacogenetics panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel provided on August 
3, 2022.
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 should be receiving the same benefits as 
Medicare and requesting admission to inpatient rehabilitation. The Plan denied your request. The Plan says 
your records do not show that you need an intensive team for your care. Services needed may be provided 
safely in a lower level of care. 
 
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, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 2, 2023, and billed with codes 87461, 87653, 87640, 87481, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on March 2, 2023, and billed with codes 87461, 87653, 87640, 87481, and 87798.