Persius/hicric huggingface dataset:
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 you would benefit from therapy services provided in 
an SNF. The Plan denied your request. The Plan says you do not require daily skilled therapies that can only be 
provided in an inpatient setting and there are no daily skilled nursing needs as your current needs can be met at 
an alternative level of care.  
 
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 clinical documentation shows that you have met all inpatient therapy goals. The 
clinical documentation does not show that you require daily skilled services on an inpatient basis in a skilled 
nursing facility, therefore the services are not 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 3, 2023, to 
August 20, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were not medically reasonable and 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 pay for home health services. Our reviewer says that 
the services were not medically reasonable and necessary. Our physician reviewer found the submitted 
documentation does not support that the enrollee received skilled nursing or skilled rehabilitation services to 
provide medically necessary treatment for the dates of service at issue. 
 
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 pay for the home health services provided on August 3, 2023, to August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 rendered 
on February 8, 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 there's a more appropriate code to report for these services. 
 
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 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump 
 
Healthcare Common Procedure Coding System (HCPCS) J1817: 
 
Insulin for administration through dme (i.e., insulin pump) per 50 units 
 
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 procedure report supports 
outpatient intravenous insulin treatment was provided. There is a more appropriate code to report for these 
services. 
 
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 96365, 96366, 96521, and J1817 rendered on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need the inserts to help with pain caused by 
your flat feet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON office visit. You say that the records provided support the medical 
necessity of the services in dispute.  The Plan denied your request. The Plan says there was no network 
deficiency, and the services were not pre-authorized.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634-59 rendered on December 8, 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 Current Procedural Terminology (CPT) code 87634-59 remains 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. 
 
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 laboratory report does include 
documentation to support that this procedure was a distinct procedural service from CPT 87798.  This 
procedure denied correctly. 
 
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 code 87634-59 rendered on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 95865 rendered on June 28, 
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 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 code 95865 is "Needle electromyography; larynx." 
 
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 units billed exceeds 
MUEs.  In this case, procedure report does not include documentation to support the additional units, and 
therefore cannot be verified. When requested, records should explain why the patient required more than the 
approved MUE for any service. The documentation submitted must support the units of service billed as 
reasonable and necessary.  
 
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 two units of procedure code 95865 rendered on June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vulva benign lesion excision (11420, 11422, 11421). 
 
You asked the Plan to pre-approve a vulva benign lesion excision. 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 follows Medicare rules. Medicare rules say that Medicare would consider the removal of any 
malignant lesion to be medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vulva benign lesion excision. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record provided 
is insufficient to establish that the elements of the coverage criteria are satisfied. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 a vulva benign lesion excision have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a vulva benign lesion excision (11420, 11422, 11421).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD) related services for dialysis 
provided on January 1, 2023, to January 11, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ESRD related services for dialysis. You say that the records provided support 
the medical necessity of the services in dispute.  The Plan denied your request. The Plan says there was no 
network deficiency for these services and the enrollee was not referred by a participating provider. The services 
were not pre-authorized.  
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for end-stage renal disease (ESRD) related services 
for dialysis provided on January 1, 2023, to January 11, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from June 20, 2022, to June 27, 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 E87.1 (Hypo-osmolality and hyponatremia) is 
sequenced as the new primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with 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 records. Our physician reviewer 
found that the enrollee presented with failure to thrive, following a recent hip injury. The enrollee was found to 
have severe hyponatremia and was admitted to the intensive care unit (ICU). While there was concern of a hip 
fracture, it appears that this was never identified.  The enrollee was secondarily treated for pneumonia and 
chronic venous stasis/cellulitis. There is no evidence of organ failure related to infection. As such, a diagnosis 
of sepsis 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 A41.9 rendered from June 20, 2022, to June 27, 2022.
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 for the enrollee 
to receive skilled therapy services daily. The Plan denied your request. The Plan says the enrollee can receive 
the care they need in another setting, such as home, a long-term care facility, or other outpatient 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 pay for the acute inpatient hospital care provided January 24, 2023, 
through January 27, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary for the enrollee.  The Plan denied your request. The Plan says services could have been provided at 
an observation level of care. 
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found resented to the emergency department with shortness of breath and was given 5 liters 
of oxygen support, steroids, antibiotics, and bronchodilators with significant improvement in symptoms. Blood 
cultures were positive with organisms typical of contamination; however, the enrollee did not exhibit clinical 
signs of bacteremia or sepsis and was improved, tolerating baseline oxygen requirements by the next day. 
Workup was otherwise negative, and the enrollee wanted to go home. It was not expected, based on the 
provided documentation, that this enrollee would have required hospital care that would likely have crossed 
two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided January 24, 2023, through January 27, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on February 1, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered 
benefit.  
  
 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator . You say that the requested device is needed because it 
allows for the auto expiratory positive airway pressure (AE) setting.  The Plan denied your request. The Plan 
says the request is not medically necessary because the records show that the ordered settings for the 
noninvasive ventilator can be delivered by a bi-level positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator . Our reviewer says 
that the criteria for coverage have not been met.  Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has COPD, although there are no pulmonary function tests to assess 
severity.  There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no arterial 
blood gas (ABG), done while stable, to document chronic carbon dioxide (CO2) retention.  If that is present, 
the enrollee may benefit from BiPAP with AVAPS during sleep. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator  have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) (code 78814).  
 
You asked the Plan to approve the PET scan. You say that you feel it is medically necessary. 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 approve the PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is only suspected of having AD. 
There was no mention in the records of her potentially having FTD. Therefore, the enrollee would not meet the 
initial requirements for coverage of a FDG PET scan for the evaluation of dementia. For Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease, this service is not currently covered by 
Medicare outside the scope of clinical trials (which are not present in this case). This too would not meet 
criteria 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 approve a positron emission tomography (PET) scan with concurrently acquired computed tomography 
(CT) (code 78814).