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

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code N17.9 
rendered from July 7, 2022, to July 9, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 N17.9. 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 enrollee presented with increasing lower extremity edema.  She was found to have new 
atrial flutter. Laboratory studies are consistent with prerenal azotemia, possibly due to decreased renal 
perfusion from the dysrhythmia. However, there is no documentation that the providers specifically addressed 
this issue, or that it had any effect on the patients hospital course. Therefore, the billing of N17.9 is not 
supported.  
 
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 N17.9 rendered from July 7, 2022, to July 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99215) rendered on 
September 21, 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 the medical records do not support the billing of code 99215. 
 
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 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
there was a high level of decision making in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (procedure code 99215) rendered on September 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.  
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary.  The Plan denied your request. The Plan says the enrollee's medical conditions appear stable and 
records to not support the need for more home health visits.  
 
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 clinical 
documentation does not specify any acute medical concerns/status changes. Documented concerns are 
regarding mobility and medical equipment. The records do not show that skilled nursing services are required 
to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
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 6 additional home health skilled nursing visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional home health care visits. 
 You asked the Plan to pre-approve home health services. You say that you are appealing this 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 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 enrollee's 
wound is healing well without any new concerns with simple daily dressing changes. The documentation does 
not show that 10 additional home health skilled nursing visits would be required to effectively provide 
treatment in order to improve the enrollee's condition or perform a maintenance program. 
 
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 10 additional home health care 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 records provided support the need for IRF care.  
The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current high functional level, the enrollee does not need specialized and 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to an IRF. The documentation does not support the necessity for admission to an 
IRF. The complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee 
may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be provided 
in a lower intensity and alternate setting such as in-home with 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 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: 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. The Plan 
denied your request. The Plan says the enrollee does not need medical monitoring from a rehabilitation doctor.  
 
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 pay for a pneumatic compression device (E0676) and appliances 
(E0673 and E0667). 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and appliances (E0673 and E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the know error DNA Specimen Provenance Assay billed 
with codes 81266 and 81265 provided on September 7, 2022. 
 
You asked the Plan to pay for the know error DNA Specimen Provenance Assay. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the know error DNA Specimen Provenance 
Assay is a statutorily excluded test. Therefore, we decided that the Plan does not have to pay for the know error 
DNA Specimen Provenance Assay billed with codes 81266 and 81265 provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75625 and 75710 rendered on January 19, 
2023. 
 
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 the medical records do not support the billing of code 75625 or the use of modifier 59 with code 
75710. 
 
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 the denied codes is: 
 
75625 - Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
75710 - Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that per the documentation the 
medical records did not support the billing of code 75625. Specifically, the operative report did not include 
documentation of radiological supervision and interpretation of an abdominal aortography. The review has 
determined that the medical records did not support the billing of code 75625. The documentation did not 
support that CPT code 75710 was distinct from CPT code 37229. This procedure is considered inclusive to 
CPT code 37229. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 75625 and 75710 rendered on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a critical care evaluation and management (E&M) visit 
provided on July 15, 2022. 
 
You asked the Plan to pay for critical care E&M visit. You say that this should be paid. The Plan denied your 
request. The Plan says this code does not meet criteria for payment. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
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 critical care E&M visit. Our reviewer says that this code does 
not meet criteria for payment. Our reviewer found the record does not support that critical care was rendered for 30 to 74 minutes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of critical care E&M visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a critical care evaluation and management (E&M) visit provided on July 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve keytruda, bevacizumab, docetaxel, carboplatin, and 
dexamethasone. 
 
You asked the Plan to pre-approve keytruda, bevacizumab, docetaxel, carboplatin, and dexamethasone. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 keytruda, bevacizumab, docetaxel, 
carboplatin, and dexamethasone. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested use of Keytruda, bevacizumab, docetaxel, carboplatin, and 
dexamethasone is not FDA-approved for the enrollees diagnosis. Programmed cell death ligand 1 (PDL1) 
needs to be > or =1% and no result is provided. The use is not supported by one of the major drug compendia 
or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of keytruda, bevacizumab, docetaxel, carboplatin, and dexamethasone have not 
been met. Therefore, we decided that the Plan does not have to pre-approve keytruda, bevacizumab, docetaxel, 
carboplatin, and dexamethasone.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 your medical conditions and functional impairments 
require an inpatient rehab stay. The Plan denied your request. The Plan says you may be eligible for a lower 
level of care, such as a skilled nursing unit, skilled nursing facility, an outpatient rehabilitation facility, or at 
home with home health care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 hospital evaluation and management (E&M) service 
provided on November 22, 2022. 
 
You asked the Plan to pay for hospital E&M visit. You say that this should be paid. The Plan denied your 
request. The Plan says this code is not supported for payment. 
 
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 99223 is initial hospital 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 are of high severity. Typically, 70 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 hospital E&M visit. Our reviewer says that this code does not 
meet criteria for payment. Our reviewer found the documentation does not support that this encounter 
contained the 3 key components including decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital E&M visit have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital evaluation and management (E&M) service provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart procedure. 
 
You asked the Plan to pre-approve Optimizer Smart. You say that this treatment is vital and beneficial to the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of this procedure 
have not been established. 
 
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 Optimizer Smart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this procedure mains the subject of multiple studies examining long-term efficacy. 
Until such studies are completed, it is premature to presume clinical outcomes and benefits. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Optimizer Smart procedure.