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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires post-acute rehabilitation in an 
IRF. 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump provided for purchase on 
December 23, 2022.  
 
You asked the Plan to pay for the infusion pump. You say that this item is necessary for blood clot prevention.  
The Plan denied your request. The Plan says this item is a capped rental item which cannot be purchased.  
 
The Plan must follow Medicare rules. Medicare rules say that capped rental items are paid on a monthly basis 
for the period of use.  
 
We looked at the file and Medicare rules. The item at issue described by code E0781 is a capped rental item. 
The claim shows that this was provided for purchase. Medicare does not cover this item for purchase. Based on 
this information, we decided that Medicare rules for coverage of the infusion pump have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump provided for 
purchase on December 23, 2022.
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 would like the enrollee to be given the 
opportunity to receive a higher level of care to regain maximum function. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare 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 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 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 enrollees current condition requires an IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
an IRF admission. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you believe the dental services should be 
provided as a medical issue and not a dental issue. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. The requested provider is not contracted with the Plan and the Plan has not 
issued an authorization for the requested out-of-network services because the requested provider is refusing to 
accept patients who have Medicare or Medicare related coverage. Therefore, we decided that the Plan does not 
have to pre-approve dental services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  an LTACH level of care is appropriate 
and the only option for the enrollee. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for admission to an 
LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has a history of memory loss. You 
say the PET scan is medically necessary to rule out early Alzheimer's disease. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is only suspected of 
potentially having Alzheimer's disease (AD). There is no clinical indication or suspicion of frontotemporal 
dementia (FTD). The enrollee does not meet diagnostic criteria for both AD and FTD, and this service would 
not be eligible for coverage. 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy with stereoscopic x-ray guidance. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that nothing in the case file suggests that standard dosimetric constraints cannot be met with a non-
proton-based treatment, and it is not plausible that proton therapy would be needed to meet these constraints. 
Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton 
therapy will reduce the low dose to normal tissues does not necessarily demonstrate that it is clinically needed relative to IMRT though, as the reductions should be clinically meaningful, and reduce toxicity risks in a 
clinically meaningful manner. Any potential benefit or detriment of proton therapy over standard IMRT is an 
investigational question. Whether proton therapy affords a benefit over other standard approaches 
(IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. 
 
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 proton beam therapy with stereoscopic x-ray guidance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve intraosseous basivertebral nerve ablation. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee has non-vertebrogenic pathology 
that could explain the source of pain.  
The Plan follows Medicare rules. Medicare rules state that intraosseous basivertebral nerve ablation is only 
covered if certain criteria are met. 
 
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 intraosseous basivertebral nerve 
ablation. Our reviewer says that the enrollee does not meet criteria for this procedure. Our physician reviewer 
found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative 
joint disorder or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services billed with diagnosis code 
A41.9 rendered from February 4, 2023, to February 9, 2023. 
 
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 review suggests DRG 193 may be 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 workup revealed pneumonia and he was started on antibiotics. The workup also 
revealed tachycardia, fever, tachypnea, hypoxia with hypotension requiring low dose oxygen and fluids. 
Creatinine was 1.59, bilirubin 0.6, platelets 355, and the patient was alert and oriented. Following fluids, 
creatinine returned to baseline (1.3-1.4). There was no reported oliguria. The hypoxia was directly related to 
the pneumonia and other organ assessments were normal or improved after initial fluids. Therefore, the 
enrollee does not meet Sepsis 3 criteria. There was insufficient evidence to support the enrollee was 
experiencing a dysregulated response to infection leading to life-threatening organ failure to justify the 
diagnosis of sepsis for this admission. Therefore, the code, A41.9, is not supported and the DRG 193 is more 
appropriate.   
 
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 acute inpatient hospital services billed with diagnosis code A41.9 rendered from February 4, 2023, to 
February 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient hospital services billed with diagnosis codes 
E46 and C34.90 rendered from June 19, 2022, to June 20, 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 a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
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 DRG 378. 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 anesthesia notes noted lung tumor and malnutrition, however, the attending notes including the 
discharge summary did not list malnutrition or lung tumor and didn't have a plan or treatment for either of these 
diagnoses in this admission to support inclusion of these codes (C34.90 or E46) for this admission. Therefore, 
DRG of 379 is more appropriate consider the inconsistent records provided.  
 
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 acute inpatient hospital services billed with diagnosis codes E46 and C34.90 rendered from June 19, 2022, 
to June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247, 75716, and 75774 rendered on 
January 9, 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 records do not support the services billed. 
 
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: 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family 
 
CPT 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
We asked our 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 reviewer found that CPT 36247 codes for 3rd order 
arterial access. The work described in this code is included in the interventional codes that have already been 
billed and covered. This access code is not separately billable.  
 
CPT 75716 codes for supervision and interpretation of bilateral extremity angiography, it can be distinct from 
the intervention procedure if there was no recent prior angiography available or if there was a change in 
condition, and there is satisfactory documentation of angiographic findings. In this case there is insufficient 
description of angiographic findings of the bilateral lower extremities to justify charging and coverage of this 
code. 
 
CPT 75774 codes for additional angiography after initial base angiography if there is documentation of a 
reposition of the catheter to obtain additional information. This is an add on code to be used with a base 
code. In this case, there is no coverable base code that has been billed to attach the add on code, and there is no 
documentation of additional information learned from a repositioned catheter with additional angiography.  
 
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 36247, 75716, and 75774 rendered on January 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71275, 93005, and 96376 billed for date of 
service January 15, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 71275 has a status indicator of Q3, which indicates a composite code. A service that is 
assigned to a composite APC is a major component of a single episode of care. The hospital receives one 
payment through a composite APC for multiple major separately identifiable services. Based on this 
information, we decided that Medicare rules for coverage have not been met. 
 
 
We find that code 93005 has a stats indicator of Q1. Payment is packaged when billed on the same claim as a 
code with a status indicator of S, T, or V, such as code 99285. Based on this information, we decided that 
Medicare rules for coverage have not been met. 
 
We find that code 96376 has a status indicator of N. Payment for this service is packaged into payment for 
other services. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 71275, 93005, and 96376 billed 
for date of service January 15, 2023.