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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 5, 
2023, through February 7, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department with shortness of breath and 
gastroesophageal reflux disease (GERD) symptoms. She tried Pepcid and inhalers at home without relief. The 
workup revealed anemia, chronic obstructive pulmonary disease (COPD) exacerbation, and fluid overload 
including pleural effusion in the setting of end-stage renal disease (ESRD) and heart failure and she was treated 
with oxygen support, antibiotics, steroids, Lasix, bronchodilators, a blood transfusion, and plans for dialysis the 
next day. Based on the enrollees likely quick resolution of symptoms with transfusion, intravenous steroids, 
diuresis and dialysis within 24 hours, it was not expected that the enrollee would likely require hospital care 
that would have crossed two midnights. Observation care would have been appropriate.  
 
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 pay for the acute inpatient hospital care provided from February 5, 2023, through February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition billed with codes B4193, B4224, and 
B4220 for date of service March 10, 2023. 
 
You asked the Plan to pay for the parenteral nutrition. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
medical records do not include a patient receipt or proof of delivery of the parenteral nutrition supplies on the 
billed date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the parenteral 
nutrition billed with codes B4193, B4224, and B4220 for date of service March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes P9603 and 36415 for December 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
P9603 and 36415 for December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on May 10, 2023. 
 
You asked the Plan to pay for the annual wellness visit. You say that you are not supposed to be charged for 
this visit. The Plan denied your request. The Plan says the member previously had an annual wellness per claim  
Q100001046420092 for date of service March 30, 2023 and the provider was paid by the Plan. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
May 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that inpatient psychiatric care 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that continued inpatient psychiatric care is not medically reasonable and necessary in this 
case. Our physician reviewer found that based upon review of the records provided, it was not expected that the 
enrollee would improve in a reasonable period of time as the enrollee did not have suicidal or homicidal 
ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any 
acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI panel provided on April 25, 2023. 
 
You asked the Plan to pay for the Guidance UTI panel. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI panel have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance UTI panel provided on April 25, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair accessory, attendant control 
(E2331). 
 
You asked the Plan to pre-approve attendant control . You say that the power sea elevation feature and 
attendant controls would both have immense medical benefits for the enrollee, and you request reconsideration. 
The Plan denied your request. The Plan says if an attendant control (E2331) is provided in addition to a 
beneficiary operated drive control system, it is not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. If an attendant control (E2331) is provided in addition to a 
beneficiary operated drive control system, it is not covered. The attendant control system is only covered when 
used in place of the member operated drive control system. It is not covered as an addition. Based on this 
information, we decided that Medicare rules for coverage of attendant control have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the power wheelchair accessory, attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator provided on June 21, 2022. 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that your doctor referred you to the 
medical supply company their office use to purchase the portable oxygen concentrator. You say that you have 
been diagnosed with a lung problem as were told you need to be on oxygen 24 hours a day. The Plan denied 
your request. The Plan says that the item in question is not covered under the enrollee's contract under any 
normal circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pay for a portable oxygen concentrator provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 88342 & 88341 billed for date of service 
April 24, 2023.  
 
You asked the Plan to pay for procedure codes 88342 & 88341. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 10 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Code 88341 is an add-on code. The 
primary code (88342) is not payable, therefore the add-on code is also non-payable. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 88342 & 88341 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 88342 & 88341 billed for date of service 
April 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs (J3490) provided on May 1, 2023. 
 
You asked the Plan to pay for the drugs. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, the National Drug Code on 
the claim is for Ketamine, however the records show Bupivacaine was administered. Based on this information, 
we decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the 
Plan does not have to pay for drugs (J3490) provided on May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 9, 2022, 
through October 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED), transferred from the skilled nursing 
facility (SNF), with an altered mental status, failure to thrive, and was non-compliant with medications 
(antibiotics) for active osteomyelitis/discitis. She was confused and disoriented. Her blood pressure was 
elevated at 140/100. She was started on intravenous (IV) antibiotics. She tolerated an oral diet. She was refused 
by the nursing facility and abandoned by the family and was admitted considering placement options with 
continued IV antibiotics. Transfer to a SNF was not possible at the time and it was expected that the enrollee 
would likely require at least two midnights of hospital care due to high risks of discharge at the time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 9, 2022, through October 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 80053, 80061, 83036, 84443, and 
85025 billed for May 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 36415, 80053, 80061, 83036, 84443, and 85025 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 36415 is collection of venous blood by venipuncture. The 
definition of code 80053 is comprehensive metabolic panel, which must include: Albumin (82040) Bilirubin, 
total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine 
(82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium 
(84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520). The definition of code 80061 is lipid panel, which must include the 
following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) 
(82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium 
(84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, 
aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520). The definition of code 83036 is 
hemoglobin; glycosylated (A1C). The definition of code 84443 is assay of thyroid stimulating hormone (TSH). 
The definition of code 85025 is blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet 
count) and automated differential WBC count. 
 
We find that CPT codes 36415, 80053, 80061, 83036, 84443, and 85025 are not supported in the medical 
record. Specifically, there is no documentation of venous blood by venipuncture to support code 36415. There 
is no physician order for codes 80053, 80061, 83036, 84443, and 85025. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36415, 80053, 80061, 83036, 84443, and 85025 billed for May 8, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone provided on  
December 29, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that the medication was 
provided to the member in the clinic on December 23, 2022. The Plan denied your request. The Plan says that 
the member was inpatient and these were self-administered drugs. 
 
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. Specifically, the Plan has not provided proof of an inpatient admission or that 
the medication was provided inpatient to substantiate their denial. Therefore, we decided that the Plan has to 
pay for medication assisted treatment, methadone provided on December 29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The 
Plan denied your request. The Plan says the requested Opdivo is not medically necessary. 
 
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 Opdivo. Our reviewer says that the 
requested Opdivo is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of recurrent thalamic diffuse infiltrating astrocytoma. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
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 the enrollee requires intensive inpatient rehabilitation 
with daily physician management, 24-hour specialized rehab nursing, and intensive therapies to optimize 
mobility and strength. The Plan denied your request. The Plan says an IRF admission 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 enrollees 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peripheral nerve stimulator placement (64555). 

You asked the Plan to pre-approve peripheral nerve stimulator placement. You say that the enrollee has tried and failed a variety of other modalities to control their pain for over a year, including medication management, surgeries, etc. You say these did not provide the enrollee with durable pain relief. The Plan denied your request. The Plan says the criteria for coverage has 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 peripheral nerve stimulator placement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the service requires a psychological evaluation, which the enrollee has not had. The request is deemed not medically reasonable and 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 peripheral nerve stimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve peripheral nerve stimulator placement (64555).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service January 9, 
2023, to January 20, 2023. 
 
You asked the Plan to pay for procedure code 99601. You say that the office was informed by two different 
representatives that no authorization was required. The Plan denied your request. The Plan says the billed code 
is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service January 9, 2023, to January 20, 2023.