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

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 15, 2022, to 
April 18, 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. The Plan denied your 
request. The Plan says the documentation does not validate the billed diagnosis. 
 
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 K65.1, defined as peritoneal abscess. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found that the enrollee presented to the hospital with abnormal computed tomography 
(CT) findings of diverticulitis with a contained perforation. The enrollee was asymptomatic on arrival. The 
enrollee was at baseline bowel and bladder habits. The surgeon noted the enrollee will likely improve with non-
operative management. In this case, there was no clinical or radiographical evidence of a peritoneal abscess. 
The review has determined that the documentation did not support diagnosis code K65.1.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on April 15, 2022, to April 18, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 2 standard power wheelchair (K0823) purchased 
on December 15, 2021. 
 
You asked the Plan to pay for the group 2 standard power wheelchair. You say that you feel you should not be 
held responsible for the cost of the wheelchair because the provider took so long to provide you with a receipt 
so you could file a claim for reimbursement. The Plan denied your request. The Plan says you did not have a 
home or physical therapy evaluation. The Plan also says there is insufficient clinical documentation to establish 
medical necessity and coverage eligibility. 
 
 
 
 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 pay for the group 2 standard power wheelchair. Our 
reviewer says that the coverage criteria have not been met. Our physician reviewer found there is no 
examination indicating he requires a power wheelchair to perform MRADLs. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pay for the group 2 standard power wheelchair (K0823) purchased on 
December 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient visit provided on November 10, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says that payment for this service is included in the fee for the 
procedure. 
 
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. The Plan did not provide documentation to verify a procedure was performed 
and paid for by the Plan; therefore, we cannot verify if this service is included in the payment of the alleged 
procedure. Therefore, we decided that the Plan has to pay for the outpatient visit provided on November 10, 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture and non-surgical management of a clavicle fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements for a home ventilator. 
 
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 a home ventilator. Our reviewer says 
that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from COPD. 
The record indicates that the enrollee was successfully treated with bilevel positive airway pressure (BiPAP) in 
the hospital. Our reviewer found that the provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. Our physician reviewer also found 
that the enrollee could be treated with a BiPAP machine with average volume-assured pressure support 
(AVAPS) capability and failure of such a device has not been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee requires an LTACH level of care and is stable for 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for SNF care provided from May 14, 2022, to May 25, 2022. We decided 
that the Plan does not have to pay for SNF care provided from May 26, 2022, to June 17, 2022.  
 
You asked the Plan to pay for SNF care provided from May 14, 2022, through June 17, 2022. You say that you 
need continued care at the SNF to be able to walk and go home again. The Plan says that the enrollee no longer 
had SNF care needs. 
 
We decided that the Plan has to pay for SNF care provided from May 14, 2022, to May 25, 2022.  
 
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.  
 
Our physician reviewer found that the SNF care was medically reasonable and necessary from May 14, 2022, 
to May 25, 2022. The records show that you made measurable progress with therapies during that time. 
Therefore, we decided that the Plan has to pay for SNF care provided from May 14, 2022, to May 25, 2022.  
 
We also decided that the Plan does not have to pay for SNF care provided from May 26, 2022, to June 
17, 2022. 
 
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.  
 
Our physician reviewer found that SNF care was not medically reasonable or necessary from May 26, 2022, to 
June 17, 2022. Our physician reviewer found that you were at a functioning level consistent with a lower level 
of care. Therefore, we decided that the Plan does not have to pay for SNF care provided from May 26, 2022, to 
June 17, 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: 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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lodging related to your medical care. 
 
You asked the Plan to pre-approve lodging. You say that you are upset because of the lack of reimbursement 
on your plan for travel and lodging. You say that you feel you should not have this expense because there are 
no available doctors that for your needed care that are closer to you. The Plan denied your request. The Plan 
says lodging is not a covered benefit except in certain transplant situations. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lodging have not been met. Therefore, we decided that the Plan does not have to pre-approve 
lodging related to your medical care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937 and 99153 billed for date of service 
November 5, 2022. 
 
You asked the Plan to pay for procedure codes 76937 and 99153. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says payment for code 76937 
is bundled into payment for code 93970. In addition, code 99153 has a PC/TC indicator of 3 and therefore may 
not be paid for services furnished to hospital patients. 
 
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 76937 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, code 99153 is a code which is considered to have only a technical component. 
These services were provided to an enrollee who was registered inpatient of a hospital. This code would not be 
appropriate to report on a physician claim in this case. 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 codes 76937 and 
99153 billed for date of service November 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venaseal procedure (36482) for varicose veins. 
 
You asked the Plan to pre-approve venaseal procedure. You say that the enrollee is in pain and having 
difficulty sleeping due to this issue, and this procedure is medically necessary. The Plan denied your request. 
The Plan says the requested service is considered investigational and has no proven benefit. Therefore, this 
service is not considered reasonable and 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 venaseal procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support the medical necessity of the procedure in 
question. The documentation of symptoms is very nonspecific. The plan is nonspecific as well, calling for ablation of multiple veins including a 2mm small saphenous vein without a plan for reassessment between 
procedures. The enrollee has a history of arthritis as well, so there needs to be clarity to ensure that the 
symptoms are related to the veins to be ablated. Without some clarity as to the nature and location of the 
enrollees symptoms and a plan specifically geared to those symptoms, we are unable to overturn the health 
plans determination on the basis of medical necessity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venaseal procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve venaseal procedure (36482) for varicose veins.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrotomy, with synovectomy, knee; anterior AND posterior 
including popliteal area rendered on October 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is part of the primary procedure and ineligible for separate payment. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure details cite the incision was made and a medial parapatellar arthrotomy was performed. A 
synovectomy in the suprapatellar pouch and medial and lateral gutters was performed. A medial release to 
expose proximal and medial tibia were performed and a portion of the infrapatellar fat pad was excised for 
exposure. However, the procedure was primarily performed to prepare the right knee for the correct placement 
of the implant. Therefore, the records do not support CPT 27335 as a separate and distinct procedure from CPT 
27447.  
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 arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area rendered 
on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on  
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this test was medically necessary. 
The Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. 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 Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Minuteman 
G3R Interspinous device, in this case, 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 a Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device (22840, 22612).