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

 
We decided that the Plan has to pay for the inpatient hospital admission provided from February 8, 2023, to 
February 15, 2023. 
 
You asked the Plan to pay for the inpatient hospital admission. You say that you are requesting the denial of the 
claim be overturned and the claim be reprocessed for payment. The Plan denied your request. The Plan says 
that the enrollee was in the same hospital within 30 days prior to this admission with the same problem. The 
Plan also says this new hospital stay cannot be approved as a separate stay. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 admission. Our 
physician reviewer found the readmission was medically necessary and was not the result from a premature 
discharge from the same hospital.  
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pay for the inpatient hospital admission provided from February 8, 2023, to February 15, 2023.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that fadfasf The Plan denied your 
request. The Plan says that the accessories are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the wheelchair accessories. Our 
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing her basic daily activities. She cannot perform pressure relief independently due to upper extremity 
weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. She currently has sacral and gluteal pressure wounds. She requires power elevating leg rests for 
positioning of her lower extremities and lower extremity spasticity. The complexity of his seating and 
positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the three 
power options via joystick. These components are required to operate 3 or more power options on a group 3 
power wheelchair. 
 
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 wheelchair accessories have been met. Therefore, we decided that the Plan 
has to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).  
 
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 lab testing provided on March 07, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration. The Plan 
denied your request. The Plan says the service was not 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 April 3, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia, anxiolysis service 
(D9230) provided on April 28, 2023. 
 
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia, anxiolysis service. You say that you  
inquired prior to your dental appointment if insurance would cover the treatment and was informed it would be 
covered, leading you to go forward with the treatment. You also say that you did not know that you needed a 
referral. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the inhalation of nitrous 
oxide/analgesia, anxiolysis is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for inhalation of nitrous oxide/analgesia, anxiolysis service (D9230) provided on April 28, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the enrollee meets Medicare criteria and 
will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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. The enrollee 
would benefit from treatment by multiple therapies, including either physical therapy or occupational therapy, 
but there is no evidence that this cannot be provided adequately in a less intensive 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 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: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on March 12, 2023, to March 
15, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee was diagnosed and treated for sepsis. The Plan denied your request. The Plan says that the principal 
diagnosis code is not 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 with primary diagnosis code A41.9, defined as sepsis, unspecified 
organism. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee presented to the hospital with altered 
mental status and was found to have a urinary tract infection. She had leukocytosis to 30 with elevated 
creatinine to 1.2. The enrollee had confirmed infection with urinary tract infection with systemic inflammatory 
response syndrome. Therefore, the documentation supports the diagnosis code of A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on March 12, 2023, to March 15, 2023, at the Diagnosis Related Group 
(DRG) originally billed.  
 
 
 
 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 the Hematology Profile Plus Panel provided on February 6, 
2023. 
 
You asked the Plan to pay for the Hematology Profile Plus Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says repeat testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that another Next-Generation Sequencing (NGS) test 
was performed on the same surgical specimen/ blood draw (specimen obtained on the same date of service).  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Hematology Profile Plus Panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the Hematology Profile Plus Panel provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Sprint PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for leg pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says Orthovisc has been prescribed for an off-label, not medically 
accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Orthovisc. Our reviewer says that 
treatment with Orthovisc is not medically reasonable and necessary in this case. Our physician reviewer found 
that the requested use of Orthovisc is not FDA-approved for the enrollee's diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a Medicare-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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Orthovisc (J7324).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyler Cascadia Prolift allograft. 
 
You asked the Plan to pre-approve Skyler Cascadia Prolift allograft. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this procedure is experimental. 
 
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 Skyler Cascadia Prolift allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Skyler Cascadia Prolift allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Skyler Cascadia Prolift allograft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 3, 
2022, to December 4, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
clinical information did not support the medical necessity of an inpatient admission. 
 
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 the 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 you presented to the emergency department with mental status changes, 
speech and gait disturbances over past month. You have a history of hydrocephalus with ventriculoperitoneal 
shunt, chronic intermittent cerebrospinal fluid (CSF) leak, history of seizures, and poor short-term memory at 
your baseline. Vitals were stable. Our reviewer found that there was no reported or observed seizure activity, 
and no focal weakness. Imaging showed shunt in stable position. Labs showed no signs of serious infection. 
Neurology was consulted and symptoms had resolved with plans for follow-up as outpatient. Our physician 
reviewer also found that based on your stability and no plans for complex treatment, it was not expected that 
you would have required hospital care that would have likely crossed 2 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 the 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 from December 3, 2022, to 
December 4, 2022.
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 the enrollee's best chance for a quicker 
recovery and more favorable outcome will be with admission to an LTACH. You also say at an LTACH the 
enrollee can receive the individualized care plan and aggressive treatment needed to ready them for the next 
level of care. 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 there is no evidence that the enrollee requires services that are not currently available.  As an LTACH and an acute care hospital (ACH) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long-term care needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardio screen panel and genedose genetic 
response report for date of service May 23, 2022.  
You asked the Plan to pay for the hereditary cardio screen panel and genedose genetic response report. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are 
not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the hereditary cardio screen panel and genedose genetic response report, was 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the hereditary cardio screen panel and genedose 
genetic response report for date of service May 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  The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements. Services needed may be provided safely in a lower level of 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 a home visit evaluation provided on March 22, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit evaluation 
provided on March 22, 2023.