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 reconsideration of denied 
authorization. The Plan denied your request. The Plan says based on the medical records received, your 
condition does not meet Medicare guidelines for an IRF admission.  
 
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 medical, rehabilitation, and nursing needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. The enrollee 
needs physical and occupational therapy but does not need intensive therapies consistent with multidisciplinary 
approach in an IRF. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 8, 2022, to 
October 11, 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 sepsis 
unspecified organism is the correct principal diagnosis. The Plan denied your request. The Plan says the 
Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient 
hospital services with the incorrect DRG. 
 
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 principal 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 reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found based on the medical records provided the 
enrollees overall condition is more accurately represented by a diagnosis of aspiration pneumonia, J69.0, than 
by sepsis, A41.9. Provided records in this case do not document a severity of illness with multisystem organ 
dysfunction of life-threatening severity to meet the diagnostic criteria for sepsis.  
 
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 October 8, 2022, to October 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's care can continue to be provided in the 
current inpatient hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy (15830). 
 
You asked the Plan to pre-approve the surgical service. You say that the extra skin you have from your weight 
loss is deteriorating your body and give you issues. You say that you have had a fungal rash for two years that 
will not go away. You say that the extra skin keeps you from enjoying exercising and being able to perform 
daily activities. The Plan denied your request. The Plan says there is no clinical documentation to support that 
the member has chronic intertrigo and rashes that are not responding to 
standard treatments. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is considered 
medically reasonable and necessary when the pannus or panniculus hangs below the level of the symphysis 
pubis causing chronic intertrigo and/or difficulty walking or functional impairment in activities of daily living. 
 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 service. Our reviewer says 
that the requested panniculectomy is not medically necessary. Our physician reviewer found the provided 
records do not document the pannus is causing chronic intertrigo that consistently remains refractory to 
appropriate medical therapy (e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months 
or that it causes difficulty walking or functional impairment in activities of daily living. Therefore, the reviewer 
found that the requested panniculectomy is 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 service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy (15830).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show radiculopathy which is a contraindication to Intracept. There is 
nerve root compression on imaging. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (81225) provided on February 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code 81479 should 
be used in this case. 
 
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 81225 is "CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), 
gene analysis, common variants (eg, *2, *3, *4, *8, *17)". 
 
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 81225 is 
supported. Our reviewer found that the record supports that the services represented by code 81225 were 
performed. Per CPT rules, it is not appropriate to use an unspecified code (81479) when an existing code 
describes the procedure performed. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the lab services (81225) provided on February 13, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (PWC) with 
single power option, sling/solid seat/back, patient weight 301 to 450 pounds (K0858) and related items (E0955, 
E1002, E1012, E1028, E2311, E2363, and E2623).  
 
You asked the Plan to pre-approve the group 3 heavy duty PWC with single power option and the related 
items. You say that the enrollee requires and meets the Centers for Medicare & Medicaid Services (CMS) 
criteria for a K0858 base and all recommended components, as they have a Group 3 qualifying diagnosis and 
require power tilt for pressure relief. You also say that this mobility device is necessary to meet the enrollee's 
mobility, medical, and functional needs in their home environment. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for single power option included with the requested K0858 
group 3 power wheelchair. The Plan also says the electronic connector is not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that power tilt and/or recline seating systems are only 
covered when certain criteria have been met. 
 
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 group 3 heavy duty PWC with 
single power option and the related items. Our reviewer says that the criteria for coverage have not been met. 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 group 3 heavy duty PWC with single power option and the related items 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty 
power wheelchair (PWC) with single power option, sling/solid seat/back, patient weight 301 to 450 pounds 
(K0858) and related items (E0955, E1002, E1012, E1028, E2311, E2363, and E2623).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric upper extremity orthosis (L7400, L6882, 
L7499, L6686). 
 
You asked the Plan to pre-approve the myoelectric upper extremity orthosis. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the requested prosthesis exceeds the 
enrollee's needs. 
 
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 myoelectric upper extremity 
orthosis. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a myoelectric prosthesis for the upper extremity can be considered 
medically necessary unless the enrollee has underlying neuromuscular disease. In this case, the enrollee has a diagnosis of multiple sclerosis and therefore the requested prosthesis is 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 the myoelectric upper extremity orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a myoelectric upper extremity orthosis (L7400, L6882, 
L7499, L6686).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on July 18, 2023. 
 
You asked the Plan to pay for the provided wheelchair. You say that the supplier would not handle insurance 
claims. The Plan denied your request. The Plan says the purchase of capped rental items cannot be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. Lump-sum purchase is not permitted.  
 
We looked at the file and the rules. The power wheelchair you have received cannot be reimbursed through a 
lump-sum purchase. Therefore, we decided that the Plan does not have to pay for the power wheelchair 
provided on July 18, 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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF as 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 power scooter. Our reviewer says 
that the requested power scooter is not medically necessary. Our physician reviewer found there is a lack of 
clinical documentation indicating the enrollees level of mobility and physical examination findings, 
specifically with regards to motor strength in the upper and lower extremities. The documentation indicates the 
enrollee is at risk for falling, but there is no indication that the enrollee cannot use a cane or walker for 
assistance with mobility or propel a manual wheelchair. There is also a lack of information as to whether the 
enrollee can safely operate the requested power scooter. Therefore, the requested power scooter is 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 the power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit on April 19, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says upon request for a review, it is the billing provider's responsibility to provide supporting 
documentation as needed. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit have been met. The 
appellant failed to provide medical records after multiple attempts by the Plan to obtain them. Therefore, we 
decided that the Plan does not have to pay for an office visit on April 19, 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 the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires 
the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-care 
functioning.  
 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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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.