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

 
We decided that the Plan does not have to pre-approve the outpatient right L2-3, L3-4 endoscopic 
foraminotomy on February 14, 2023. 
 
You asked the Plan to pre-approve the outpatient right L2-3, L3-4 endoscopic foraminotomy. You say that  the 
surgery was medically necessary and therefore payable. The Plan denied your request. The Plan says the 
outpatient right L2-3, L3-4 endoscopic foraminotomy because the surgery does not meet the requirement of the 
enrollee's plan of benefit and is excluded from coverage. 
 
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 right L2-3, L3-4 
endoscopic foraminotomy. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the medical records do not show an 
adequate trial of physical therapy for radiculopathy. The medical records do not contain a physical exam 
showing L3 and L4 radiculopathy. Also, the endoscopic procedure is experimental, and more research is 
needed. 
 
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 right L2-3, L3-4 endoscopic foraminotomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the outpatient right L2-3, L3-4 endoscopic 
foraminotomy on February 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 12-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips for 
rehabilitation. The Plan denied your request. The Plan says the requested trips exceed your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
12-trip limit.
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 services are medically necessary for the 
enrollee's complex care needs. 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 the enrollee does not require treatment by multiple therapies. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool. 
 
You asked the Plan to pre-approve the stool. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue 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 pre-approve a tub stool.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code I50.21 
rendered from July 23, 2021, to July 25, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says the DRG was updated. 
 
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 I50.21. 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 services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of I50.21 (Acute systolic (congestive) heart failure). In this case, the 
documentation does not consistently and completely support the assigned secondary diagnosis code. The 
decision to remove the secondary diagnosis code and adjust the DRG is upheld.  
 
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 billed with diagnosis code I50.21 rendered from July 23, 2021, to July 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 1, 2022, to June 
2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that patient status code 06 should be reported in all cases 
where the HHA is aware that the period of care will be paid a partial period payment adjustment.  
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 06 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from June 
1, 2022, to June 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance cholangiopancreatography (MRCP). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the health plan does not cover the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had a negative computed tomography (CT) of the abdomen and pelvis on April 18, 
2023. The enrollee's liver function tests continue to rise, including Alkaline Phosphatase. As such, a primary 
biliary tract disease process should be ruled out. MRCP would be appropriate. This procedure is not screening 
test. It is a non-experimental diagnostic test and is covered by Medicare when appropriate symptoms are lab 
work are appropriate, which is true in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance cholangiopancreatography (MRCP).  
 
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: 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 were independent and active before your 
hospitalization and want to return to being independent. The Plan denied your request. The Plan says you do 
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 you do not require treatment by multiple therapies. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit rendered by a chiropractor on December 12, 
2022. 
 
You asked the Plan to pay for the visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit rendered by a chiropractor on December 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor. 
 
You asked the Plan to pre-approve an MCOT monitor. You say that the records provided support the need for 
the requested services. The Plan denied your request. The Plan says the request is not medically necessary 
because records show the enrollee's irregular pulse is caused by premature atrial complexes. The Plan says that 
the enrollee has no other symptoms.  
 
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 MCOT monitor. Our reviewer says 
that an MCOT monitor is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has premature atrial contractions (PACs) on an office electrocardiogram (ECG) 
and has no symptoms. There is no supportive evidence that the ordering practitioner documented any standard, 
non-MCOT, ambulatory ECG monitoring. There is insufficient documentation to support the medical necessity 
for an MCOT monitor in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes 
rendered on October 8, 2022. 
 You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied 
your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are 
not used in clinical management, exceeds the needs of the enrollee. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation did not provide evidence of a then recent unexpected results from a 
urine drug screening prior to ordering this confirmation drug test as required. There was no clinical indication 
for a confirmation test at all when screening urine testing would have been more appropriate in this situation. 
Also, 15-21 drug classes were far more than were applicable to this case as the enrollee was only prescribed 
two drug classes at risk of abuse and there were no signs of other drugs (illicit, etc.) to warrant additional drug 
classes. The criteria for the definitive testing is not met, nor was testing for 15-21 drug classes medically 
necessary for this enrollee at that time.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (UDT) for 15-21 drug classes rendered on October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a noninvasive 
ventilator (E0466). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this the 
record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. 
The record indicates that the enrollee was successfully treated with average volume-assured pressure support 
(AVAPS) settings. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with AVAPS capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) months continued use of a noninvasive ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for November 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 items/services at issue were 
reimbursed by the Plan on December 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says that the ventilator is not necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the enrollee has had a home ventilator since at least February of this year. A compliance report 
covering February 2nd to May 2, 2023, showed 80 percent of days with at least 4 hours of use per day. The 
records do not include any arterial blood gas data to document chronic carbon dioxide (CO2) retention. If that 
is present, BiPAP with average volume-assured pressure support (AVAPS) would likely meet the enrollee's 
needs. This has not been tried and shown to fail as an outpatient. Medicare does not cover a home ventilator 
when used at settings that can be provided with bilevel positive airway pressure (BiPAP). The ventilator should 
be approved for an additional 3 months to allow time for transition to BiPAP.   
 
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 home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve the continuation of a home ventilator (E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) provided on December 8, 
2022. 
 
You asked the Plan to pay for a physician office visit. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. 
 
We looked at the file and Medicare rules. The primary diagnosis code reported for the service at issue, 
S06.5X9S Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela, is a 
sequela code and should not be reported as a primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of a physician office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for a physician office visit (99213) provided on December 8, 2022.