Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32551 for date of service June 26, 2021. 
 
You asked the Plan to pay for procedure code 32551. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 32551 is tube thoracostomy, includes connection to 
drainage system (eg, water seal), when performed, open (separate procedure). 
 
We find that CPT code 32551 is not supported in the medical record. Specifically, the medical records indicate 
tracheostomy, emergency procedure; was performed. This means there is a more appropriate code to be billed 
for the services rendered. Based on this information, we decided that Medicare rules for coverage of procedure code 32551 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
32551 for date of service June 26, 2021.
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 are requesting an expedited reconsideration 
stating the enrollee currently meets IRF admission criteria. 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve entropion repair. 
 
You asked the Plan to pre-approve entropion repair. You say that entropion repair is medically necessary for 
this patient due to the patient's eye irritation. The Plan denied your request. The Plan says the requested 
entropion repair is not medically necessary because preoperative photographs documenting functional 
impairment have not been submitted.  
The Plan follows Medicare rules. Medicare rules say that in order for eyelid surgery to be covered, there must 
be photographic documentation clearly demonstrating the anatomic defect. 
 
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 entropion repair. Our reviewer says that 
entropion repair is not medically necessary in accordance with Medicare rules. Our physician reviewer found 
the medical record documents patient complaints of red, watery, and irritated eyes. The records also document 
right lower lid entropion with recommended treatment with lubricating eye drops.  Although these complaints 
are documented, there were no pre-operative photos submitted for review to determine the severity of the 
patient's condition or defect. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of entropion repair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve entropion repair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have right leg pain due to lumbar radiculopathy. The Vertiflex device is 
experimental. More research is needed. Therefore, you do not meet criteria for the requested services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zimmer Biomet Mobi C identified with code 22856 and 
Medtronic BMP OR Cerapedics I Factor identified with code 20930. 
 
You asked the Plan to pre-approve Zimmer Biomet Mobi C and Medtronic BMP OR Cerapedics I Factor. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services 
are 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 Zimmer Biomet Mobi C and Medtronic 
BMP OR Cerapedics I Factor. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have a diagnosis of cervical disc 
displacement. You have been approved to have spinal surgery. MOBI C disc replacement is experimental when combined with fusion. Factor graft is also experimental. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zimmer Biomet Mobi C and Medtronic BMP OR Cerapedics I Factor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Zimmer Biomet Mobi C identified 
with code 22856 and Medtronic BMP OR Cerapedics I Factor identified with code 20930.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS) and a back-
up rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP 
or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 
necessary." The LCD requires: "There must be enough detailed information in the medical record to justify the 
treatment selected." The provided records in this case do not provide adequate detailed information to meet 
Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve InnovaMatrix AC wound dressings. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records document that the enrollee has 
undergone multiple applications of Innova Matrix, as well as routine standard diabetic ulcer care. Between 
March 23, 2023, and May 11, 2023, the wound is noted to have dramatically reduced in size. The continued use 
of Innova Matrix is therefore reasonable and medically necessary based on the submitted documentation. 
 
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 pre-
approve InnovaMatrix AC wound dressings.  
 
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 laboratory services (81479) provided on March 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the payment for these services is 
included in the payment to the hospital where the enrollee was registered inpatient at the time. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to inpatients are 
covered under part A and are covered by the prospective payment rate or reimbursed as reasonable costs under 
Part A to hospitals excluded from the prospective payment system. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the records provided show that the enrollee 
was registered inpatient from March 10, 2022, to March 26, 2022, which includes the date in question. This means that these services would be paid to the hospital. Therefore, we decided that the Plan does not have to 
pay for laboratory services (81479) provided on March 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged home and care for 
yourself. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation rendered on November 11, 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 CPT 75710 is included in CPT 37225. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
angiography extremity, and an intervention performed femoral artery, which includes radiogical supervision 
and interpretation. Therefore, modifier -59 distinct procedural service cannot be verified. 
 
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 angiography, extremity, unilateral, radiological supervision and interpretation rendered on 
November 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria (J1602). 
 
You asked the Plan to pre-approve Simponi Aria. You say that you would like the Plan to consider approving 
golimumab, as this would be most cost effective compared to numerous hospitalizations for disease activity. 
The Plan denied your request. The Plan says Medicare and other sources do not support the use of this drug for 
the enrollee's condition. 
 
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 Simponi Aria. Our reviewer says that 
Simponi Aria is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Simponi Aria (J1602) is not FDA-approved for the enrollees diagnosis. Our reviewer also 
found that its use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria (J1602).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 30, 2021, to July 
4, 2021, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code N17.9, described as 
Acute kidney failure, unspecified. 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 documentation does not support the billed 
code. Our physician reviewer found that in this case, the creatinine at its highest level was 1.65. There was no 
clinical or laboratory evidence of acute kidney injury/acute tubular necrosis.  
 
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 provided on June 30, 2021, to July 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative radiation therapy (IORT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are 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 the requested services. Our physician 
reviewer found that the enrollee has a diagnosis of clinical invasive ductal carcinoma of the right breast. A 
lumpectomy is scheduled. The documentation states that if the enrollees second biopsy is negative and the 
imaging does not show any evidence of disease elsewhere, then the enrollee is a candidate for IORT. The 
physician notes that there is a small increased risk of recurrence with IORT versus whole breast radiation, but 
this is unlikely to translate into survival difference. There is insufficient evidence in the medical literature 
supporting the use of IORT in this setting. Evidence regarding the safety of IORT remains unclear at this 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraoperative radiation therapy (IORT).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request for an MRI is not medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that during the last 
encounter the enrollees physical exam was abnormal and the enrollee could not walk well on heels or toes.  
Patellar reflexes are diminished, and Achilles reflexes are absent. Due to these post-operative physical findings, 
the criteria for the MRI is met. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the lumbar spine.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-area referral for home health services. 
 You asked the Plan to pre-approve the out-of-area home health services. You say that you had surgery awhile 
back and need services out-of-network. The Plan denied your request. The Plan says you are residing outside of 
the covered service area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested home health service is not considered a covered benefit for members living outside of a covered 
service area. According to the Plan's records, you reside in Merced in the following zip code: 95348. The city 
and zip code is not in a covered service area of your Plan. Therefore, we decided that the Plan does not have to 
pre-approve an out-of-area referral for home health services.