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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request for an IRF admission is not 
medically necessary as Medicare criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anterior abdominal hernia repair as an outpatient 
surgery. 
 
You asked the Plan to pre-approve an anterior abdominal hernia repair as an outpatient surgery.. You say that 
the enrollee needs this surgery. The Plan denied your request. The Plan says this surgery is not covered as an 
outpatient procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that services designated as "inpatient only" are not 
appropriate to be furnished in an outpatient department. 
 
We looked at the file and Medicare rules. We verified that this surgery is considered an inpatient only 
procedure. Based on this information, we decided that Medicare rules for coverage of an anterior abdominal 
hernia repair as an outpatient surgery. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an anterior abdominal hernia repair as an outpatient surgery.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services for date of service April 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that these services are included in the hospital stay or surgery. 
 
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 file shows that the Plan states that these services are included in 
the hospital stay or surgery. However, the documentation does not explain what hospital stay or surgery these 
services are included in. No Medicare rules were provided to support this denial. No other denial rationale was 
provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
laboratory services for date of service April 14, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery to remove and place a dental implant. 
 
You asked the Plan to pre-approve dental surgery. You say that you disagree with the denial for dental surgery. 
The Plan denied your request. The Plan says the requested service is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
dental surgery to remove and place a dental implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 12, 2022, to 
April 15, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as 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 documentation does not support the billed code. 
Our physician reviewer found the enrollee presented with shortness of breath. He was treated for pneumonia 
and rhinovirus. The enrollee wears oxygen at baseline. There is no evidence of systemic symptoms, organ 
failure and hemodynamic instability.  
 
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 April 12, 2022, to April 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The home ventilator is requested to 
reduce the work of breathing and to improve lung status. A device mode of average volume-assured pressure 
support (AVAPS-AE) is requested. Medicare does not cover a ventilator for this use and the services are 
therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation trips for upcoming therapy and doctor's appointment that are scheduled for the year. The Plan 
denied your request. The Plan says additional trips would exceed your benefit limit. 
 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 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
fifty-two (52) one-way transportation trips out of the allowed seventy-two (72) one-way trips approved. Once 
72 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93280 and 93312 for date of service 
September 7, 2021, to September 8, 2021. 
 You asked the Plan to pay for procedure codes 93280 and 93312. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 93280 is programming device evaluation (in person) with 
iterative adjustment of the implantable device to test the function of the device and select optimal permanent 
programmed values with analysis, review and report by a physician or other qualified health care professional; 
dual lead pacemaker system. 
 
The CPT Code Manual definition of code 93312 is echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, 
interpretation and report. 
 
In this case, we have confirmed that code 93280 is a column II code to column I code 33208. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
We find that CPT code 93312 is not supported in the medical record. Specifically, the operative report did not 
include documentation of echocardiography, transesophageal, real-time with image documentation (2D) (with 
or without M-mode recording); including probe placement, image acquisition, interpretation and report; 
therefore, code 93312 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 93280 and 93312 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93280 and 
93312 for date of service September 7, 2021, to September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion; single level (22869) 
 
You asked the Plan to pre-approve Vertiflex device. You say that the enrollee has suffered from this condition 
for several years and has greatly impacted his quality of life. You highly recommend this minimally invasive 
procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion 
procedure. The Plan denied your request. The Plan says unproven and not medically necessary procedures are 
not covered by Medicare. 
 
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 Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental and investigational. There is more research needed due to 
insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion; single level (22869)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Signatera genetic testing (81479). 
 
You asked the Plan to pre-approve the genetic testing. You say that please help you to pay for this bill. The 
doctor ordered it but you have no money to pay for it. The Plan denied your request. The Plan says the records 
do not support that the enrollee meets the criteria and 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 the genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found This enrollee with metastatic breast cancer had testing for minimal residual disease 
(MRD) with Signatera sent on November 14, 2022. The use of MRD testing is not supported by the National 
Comprehensive Cancer Network (NCCN) Guidelines or other established guidelines for monitoring breast 
cancer as it is not a standard of care. The service was not reasonable or medically 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Signatera genetic testing (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99226 for date of service August 
27, 2022, and August 28, 2022. 
 
You asked the Plan to pay for procedure codes 99220 and 99226. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
The CPT Code Manual definition of code 99226 is subsequent observation care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A 
detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 procedure codes 99220 and 99226. Our reviewer says that 
the documentation does not support the codes billed. Our reviewer found the enrollee was treated in the 
hospital for abdominal pain after eating corn. The documentation does not support a comprehensive or detailed 
history or physical, or medical decision making of high complexity. Therefore, codes 99220 and 99226 are not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99220 and 99226 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99220 and 99226 for date of service August 27, 2022, 
and August 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on January 1, 
2023. 
 
You asked the Plan to pay for the emergency room services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the enrollee received services in a freestanding ER. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Medicare covers services in an emergency department only if the 
emergency clinic is affiliated with a hospital. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services 
provided on January 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to modify the course of 
treatment as needed to maximize the enrollee's capacity to benefit from the rehabilitation process. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
inpatient rehabilitation facility. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 You asked the Plan to pre-approve Orthovisc. You say that the previous request for Euflexxa has been 
cancelled. You say that the office does not have Euflexxa available. You say that the contract pharmacy does 
not have Euflexxa available either. You also say that you would like an exception to be made. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drug, Euflexxa. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drug, Euflexxa. The reviewer found there is no 
documentation provided indicating that the plans preferred drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.