Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioengineered synthetic skin (Q4187, 15271, Q4186). 
 
You asked the Plan to pre-approve bioengineered synthetic skin. You say that the enrollee is healing too slow 
with his current wound VAC. The Plan denied your request. The Plan says the request is not medically 
necessary at this time. The records indicate that the enrollee's wound is healing and wound involves muscle. 
 
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 bioengineered synthetic skin. 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 nonhealing ulcers to LLE that started last year. Most 
recently treated surgically May 16, 2023, with LLE vascular intervention and placement of Wound VAC to L 
inner thigh wound. On May 25, 2023, the initial eval-L medial thigh was a tall and thin convex lens shaped 
wound measuring 4cm x12cm x3-4mm. Muscle exposed, healthy wound bed, no signs of infection. VAC 
changed. Nutrition discussed for healing. On June 13, 2023, follow-up L medial thigh measured 4.5cm x 
11.5cm x 4mm. Wound slowly healing, no signs of infection. The enrollee is performing dressing changes at 
home. The review has determined that the requested item is not medically necessary. Per the reviewed 
documentation, the wound has had significant healing with standard wound care as of the measurements of 
June 27, 2023. The enrollee does not meet criteria for the skin substitutes. The skin substitute is not 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 bioengineered synthetic skin have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioengineered synthetic skin (Q4187, 15271, Q4186).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 27, 2022, 
to October 1, 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 
diagnosis of sepsis was supported by the medical record.  The Plan denied your request. The Plan says 
diagnosis code A41.9 (Sepsis, unspecified organism) is not supported in the medical record. Removal of this 
diagnosis resulted in a lower DRG being paid. 
 
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 A41.9 (Sepsis, unspecified 
organism). 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 diagnosis code A41.9 (Sepsis, unspecified organism) is not 
supported by the medical record. Our physician reviewer found the patient is a 66-year-old male with liver 
cirrhosis and chronic kidney disease who presented to the hospital with abdominal pain. His workup revealed 
pancreatic mass with ascites which was treated with paracentesis revealing peritonitis. He was started on 
antibiotics and IV fluids. He had hyponatremia which was documented to likely be related to cirrhosis. The 
patient did not require oxygen support, and creatinine, platelets, bilirubin were stable/normal/baseline 
following initial treatments. He was alert and oriented and had no reported oliguria, and stable blood pressure. 
Sepsis 3 criteria was not met. The patient did not have sufficient evidence of a systemic dysregulated response 
to infection leading to significant organ failure that is life-threatening to support the diagnosis code, A41.9 
(sepsis).   
 
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 27, 2022, to October 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
procedure and the procedure 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 left heart catheterization. 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 coronary artery disease.  The enrollee had a negative 
stress test in December 2021 and reported no chest pain on recent office visit. Documentation does not reveal 
the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary in this enrollees 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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory service (81599) provided on February 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the claim shows that a DEX Z-Code was provided on the claim. 
Therefore, we decided that the Plan has to pay for the laboratory service (81599) provided on February 10, 
2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95117 billed for date of service December 
20, 2022.  
 You asked the Plan to pay for procedure code 95117. You say that the claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95117 is 1. The MAI value for this code is 2. You billed two (2) units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95117 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95117 billed for date of service December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable wireless pulmonary artery pressure 
sensor with delivery catheter, including all system components (C2624) and a transcatheter implantation of 
wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested device has been proven 
to help reduce heart failure related hospitalization. The Plan denied your request. The Plan says the records do 
not show that the enrollee continues to have New York Heart Association Class III symptoms after the 
Mitraclip procedure. Additionally, the records indicate that the enrollee's glomerular filtration rate is less than 
25. 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable wireless pulmonary artery pressure sensor with delivery catheter, 
including all system components (C2624) and a transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring (33289).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health visits. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 records 
show that the enrollee has been medically stable without any recent exacerbations of chronic medical problems 
or hospitalizations. The enrollee does not require additional skilled nursing services. 
 
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 additional home health visits.
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 the enrollee's acute and chronic medical conditions 
require daily, medically necessary oversight by a physician. The Plan denied your request. The Plan says that 
the request 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 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 1, 2022, to 
November 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA for 
payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 1, 2022. The NOA was not received by the Plan until February 
14, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 1, 2022, to November 26, 2022.
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 enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
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: 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 enrollee exceeds the criteria for an 
LTCAH admission, and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says admission to the LTACH is 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic radiology procedures of the lower 
extremities. 
 
You asked the Plan to pre-approve diagnostic radiology procedures of the lower extremities. You say that the 
services are medically necessary. The Plan denied your request. The Plan says we called your providers office 
on April 27, 2023, to obtain a doctor's order for this request. We were informed that your provider will need to 
see you first before an order can be submitted. X-rays are not part of the services that you can get without first 
getting approval from your provider, so this request has been denied. 
 
The Plan contract says in most cases, you need approval from your PCP before using other providers. 
 
We looked at the file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of diagnostic radiology procedures of the lower extremities have not been met. Therefore, we decided 
that the Plan does not have to pre-approve diagnostic radiology procedures of the lower extremities.