Persius/hicric huggingface dataset:
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 for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve aquatic therapy. You say that the services are medically necessary to help 
you with your chronic pain you are experiencing. The Plan denied your request. The Plan says you do not meet 
the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 aquatic therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found aquatic therapy is not a substitute for land therapy but serves as transition to land 
therapy. It is effective when gravity inhibits range of motion activity. You have full range of motion against 
gravity. Aquatic therapy is not medically necessary as the aquatic therapy is not as effective as land therapy for 
your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on November 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
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 use of code 99223 is 
not supported by the records provided. Our reviewer found that the provided documentation did not clearly 
support a comprehensive history or physical, and did not support decision-making of high complexity.  
 
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 the services (99223) provided on November 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 2, 2022, to 
September 30, 2022. 
 You asked the Plan to pay for the home health services. You say that this patient has out-of-network benefits, 
so this claim should be paid. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 2, 2022. The NOA was not received by the Plan until November 
5, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 2, 2022, to September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine injection provided on January 4, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that you have correctly billed the services at issue. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure denoted by code 20610 provided on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the services at issue have not been met. Therefore, 
we decided that the Plan does not have to pay for Bupivacaine injection provided on January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve renal transplantation services (50360) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve renal transplantation. You say that the enrollee wants to continue receiving 
care with the provider at issue. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
renal transplantation services (50360) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 24, 2022, to July 
22, 2022. 
 You asked the Plan to pay for the home health services. You say that you claim that you timely filed the NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 25, 2022. The NOA was not received by the Plan until October 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that although you may have sent the NOA to the Original Medicare 
intermediary in February of 2022, you did not submit the required NOA to the Plan until October. Therefore, 
we decided that the Plan does not have to pay for home health services provided from June 24, 2022, to July 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for repair or replace broken retentive clasping materials 
(D5630), replace broken teeth (D5640 x5) and rebase maxillary partial denture (D5720) provided on September 
22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you say this was an injury accident and 
treatment was medically necessary. The Plan denied your request. The Plan says the claim was processed 
correctly according to your dental benefit and is not eligible for coverage under the medical benefit. 
 
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, certain limitations apply. The record 
shows the benefit for replacing broken teeth was exhausted on date of service September 22, 2022 when the 
Plan covered the repair of broken retentive clasping materials. The record also shows the benefit for denture 
rebase was processed correctly at 50% of the allowed amount. Therefore, we decided that the Plan does not 
have to pay more for repair or replace broken retentive clasping materials (D5630), replace broken teeth 
(D5640 x5) and rebase maxillary partial denture (D5720) provided on September 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 17, 2022, to 
April 20, 2022, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of diagnosis code N17.9. 
 
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 N17.9. 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 submitted records do not support the billing of diagnosis code N17.9. Our physician reviewer found the 
enrollee presented to the hospital with complaints of generalized weakness, dizziness, and abdominal pain. 
Laboratory data reflected the creatinine was 3.1 on April 17, 2022, and 2.1 on April 18, 2022. The enrollee had 
stage IV chronic kidney disease and unknown baseline creatinine. There is no documented increase in serum 
creatinine to 4.0 mg/dl or higher with an increase of at least 0.5 mg/dl. After optimal hydration, there's no 
increase in serum creatinine (which is known or presumed to have occurred within the prior 7 days) to 1.5 
times or more from baseline, or urine volume < 0.5 ml/kg/h for six hours. The records therefore do not support 
diagnosis N17.9.  
 
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 April 17, 2022, to April 20, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930), arthrodesis (22533), surgery to put 
in a device at the base of the neck to make the spine stable (22840), and insertion of interbody biochemical 
device (22853).  
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee's pain is a ten out of ten. You 
say that their pain prevents them from being able to perform activities of daily living (ADLs). You also say that 
a direct lumbar interbody fusion is medically necessary. The Plan denied your request. The Plan says the 
requested procedure 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 the surgical services. Our reviewer says 
that the requested surgical services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The reviewer found that dynamic 
flexion/extension films are not provided to potentially assess the amount of movement (instability) at the 
requested surgical level. The reviewer found that detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the reviewer 
found that the requested allograft, arthrodesis, surgery to put in a device at the base of the neck to make the 
spine stable, and insertion of an interbody biochemical device are not medically reasonable or 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 the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft (20930), arthrodesis (22533), surgery to put in a device at the base of 
the neck to make the spine stable (22840), and insertion of interbody biochemical device (22853).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a wheelchair controller and two or more motors (E2311), 
expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve a wheelchair controller and two or more motors, expandable controller, and 
harness. You say that the enrollee requires the requested wheelchair base and all of the recommended 
components to meet their mobility, medical, and functional needs in their home. The Plan denied your request. 
The Plan says that although there are three requested power options (tilt, recline and elevating leg rests), there 
is not a medical need to control these power options through the joystick. 
 
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 a wheelchair controller and two or more 
motors, expandable controller, and harness. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee is functionally non-
ambulatory and requires a power wheelchair for mobility and performing their basic daily activities. The 
enrollee cannot perform pressure relief independently due to weakness and requires a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. Our reviewer found that the enrollee also 
requires power elevating leg rests for positioning of their lower extremities and spasticity. The complexity of 
the enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our 
physician reviewer also found that the expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the three power options, including, tilt, recline and 
elevating leg rests, by a joystick. 
 
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 wheelchair controller and two or more motors, expandable controller, and 
harness have been met. Therefore, we decided that the Plan has to pre-approve a wheelchair controller and two 
or more motors (E2311), expandable controller (E2377), and harness (E2313).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code J96.01 
rendered from August 24, 2021, to August 26, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the review resulted in a DRG change from 205 
to 206. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 205. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with shortness of breath. Vitals were stable and oxygen saturation (SpO2) was 96% 
with the patient awake and alert and not in acute distress. There was on brief drop in oxygen saturation to 88% 
after his endoscopy that didn't require high flow oxygen, intubation, bilevel positive airway pressure (BiPAP), 
or vent support and quickly resolved. Therefore, the code, J96.01 (acute respiratory failure with hypoxia) is not 
sufficiently supported in the records for this admission. DRG 206 would be more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code J96.01 rendered from August 24, 2021, to August 26, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport and ground mileage. 
 
You asked the Plan to pre-approve the ambulance service, basic life support, non-emergency transport and 
ground mileage. You say that this is a medical necessity due to the enrollee's low back pain. The Plan denied 
your request. The Plan says the clinical given doesnt show a covered destination as a doctor's appointment at 
the doctors office is considered a covered destination. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life 
support, non-emergency transport and ground mileage. Our reviewer says that the requested ambulance 
transport and ground mileage are not medically necessary. Our physician reviewer found the transportation via 
ambulance to/from the doctor's office is not medically necessary.  
 The enrollee is not shown to require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport.  Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance 
service, basic life support, non-emergency transport and ground mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable scooter (K0806). 
 
You asked the Plan to pre-approve a foldable scooter. You say that the person that did your evaluation had too 
many inconsistencies. You say that it was reported your current scooter is in good condition without even 
looking at it. You say that you are moving soon and do not have somewhere to store your scooter. You also say 
that you would like a new evaluation with the first vendor you saw for an evaluation. The Plan denied your 
request. The Plan says your current wheelchair is in good working condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 power operated vehicles (POVs) have 
added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a foldable scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a foldable scooter (K0806).