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

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care from September 23, 
2023, forward. 
 
You asked the Plan to pre-approve the continued inpatient hospital care. You say that the records provided 
support that continued inpatient care is medically necessary. The Plan denied your request. The Plan says 
continued inpatient care 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 continued inpatient hospital care. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 76-year-old female who presented to the hospital with 
chest pain and a COVID-19 infection. The enrollee was treated with antibiotics for a suspected urinary tract infection (UTI) and was treated with morphine, fluids, aspirin, and other supportive care. She was documented 
to have been awaiting guardianship and placement and had been refusing medication and testing. COVID 
isolation precautions were completed on September 16, 2023. Documentation from September 23, 2023, 
showed the enrollee as stable hemodynamically, still refusing care, and appropriate for a lower level of care 
while awaiting placement. 
 
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 continued inpatient hospital care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient hospital care from September 23, 2023, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says the requested neuropsychological testing 
does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision are 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that this enrollee has had difficulty with pain where the 
physician is requesting neuropsychological testing for assessment of pain. The documentation presented does 
not agree with the LCD for this case as all psychological tests should be administered, scored and interpreted 
by a trained professional including a psychologist, clinical psychologist or advanced nurse practitioner with 
education in the area or a physician assistant who works with the psychiatrist with expertise in the appropriate 
area. Utilizing the criteria from the Medicare LCD that this testing is intended to diagnose and characterize the 
neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including 
detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential 
diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central 
nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system 
disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the criteria as it is 
unclear the reasoning for the testing to be obtained.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 20, 
2023, to January 21, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the need 
for the inpatient care in dispute. The Plan denied your request. The Plan says the clinical does not support a 
reasonable expectation that the enrollee would require hospital services extending beyond two midnights. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of admission; it was not reasonable to expect that two midnights of 
inpatient level care would be medically necessary. The enrollee could have been safely monitored on 
observation status. The enrollee was indeed discharged after only one midnight or 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 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 on January 20, 2023, to January 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120) and core 
buildup, including any pins (D2950). 
 
You asked the Plan to pre-approve fixed partial denture sectioning and core buildup. You say that the services 
are necessary. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed 
partial denture sectioning (D9120) and core buildup, including any pins (D2950).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an ILR in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegcetacoplan. 
 
You asked the Plan to pre-approve Pegcetacoplan. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Pegcetacoplan. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found The review has determined that the 
documentation does not support that the Pegcetacoplan is medically reasonable and necessary or safe and 
effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pegcetacoplan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pegcetacoplan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with codes 80307 and G0483 for April 
4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the physician order is insufficient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The submitted physician order does not sufficiently detail the billed 
charges. Therefore, we decided that the Plan does not have to pay for the drug testing billed with codes 80307 
and G0483 for April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 80307, 83789, and 
G0480 for April 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 80307, 83789, and G0480 for April 5, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch block services. 
 
You asked the Plan to pre-approve genicular nerve branch block services. You say that the enrollee is in severe 
pain and having a hard time walking. You say that the enrollee cannot have surgery due to other health issues. 
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 genicular nerve branch block services. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental/investigational therapy. It is the subject of 
ongoing clinical trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve branch block services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular nerve branch block services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is no longer in acute stage and will need 
the skilled nursing facility. The Plan denied your request. The Plan says that criteria for admission to the SNF 
have not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's past level of function is documented as modified independent prior to 
initial treatment for a heel wound. The enrollee currently requires minimal to maximum assistance with 
mobility and self-care tasks, is non-weight bearing on their right lower limb, and on a modified diet. The 
enrollee requires ongoing speech therapy for cognitive impairments, and evaluating therapists recommend 
ongoing therapy in a skilled nursing facility. The clinical documentation shows that the enrollee has wound 
care needs, frequent monitoring of electrolytes and vitals with resolving encephalopathy; thus, they would be 
expected to require frequent assessment by skilled nursing. The documentation supports the medical necessity 
of daily skilled services on an inpatient basis 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  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 the acute inpatient hospital care provided from April 1, 2022, 
to April 5, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were urgent and 
medically necessary, and authorization was not able to be obtained. The Plan denied your request. The Plan 
says inpatient hospital care was not authorized. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the documentation describes an expectation that the enrollee would not have 
required hospital services that would have crossed two midnights as workup for bladder cancer could have 
been performed at a lower level of care with the enrollee hemodynamically stable and there was no more 
hematuria noted.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2022, to April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve procedure (64454). 
 
You asked the Plan to pre-approve a genicular nerve procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a genicular nerve procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks for the treatment of chronic knee pain (e.g., 
degenerative joint disease, osteoarthritis, treatment prior to knee replacement or following knee replacement or 
instead of knee replacement) are experimental/investigational. It has not been scientifically demonstrated to improve patient clinical outcomes. The review has determined that the items/services at issue in this case 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 a genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve procedure (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 29, 2021, 
to December 3, 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 
diagnosis of A41.9 (Sepsis, unspecified organism) is supported by the medical record, so the claim should be 
paid at the DRG originally billed. The Plan denied your request. The Plan says the billed diagnosis code of 
A41.9 (Sepsis, unspecified organism) is not supported by the medical record. The records did not confirm that 
the patient met Sequential Organ Failure Assessment (SOFA) criteria for this diagnosis. As a result, a lower 
DRG was paid. 
 
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 a diagnosis code of A41.9 (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 diagnosis code of A41.9 (Sepsis, unspecified organism) is not 
supported by the medical record. Our physician reviewer found the physician diagnosed secondary to 
community acquired pneumonia and Systemic Inflammatory Response Syndrome (SIRS) criteria. The 
physician also noted a SOFA score of 0. The enrollee did not have hemodynamic, neurologic, renal, hepatic, 
hematologic compromise and was not hypoxic. SIRS criteria as the diagnostic criteria for sepsis have been 
thoroughly discredited. The International criteria for sepsis are SOFA based. The enrollee did not have a SOFA 
score indicating sepsis. The plan has coded correctly.  
 
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 November 29, 2021, to December 3, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 28, 2022, 
to October 1, 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 
have billed the services at issue correctly. The Plan denied your request. The Plan says the DRG originally 
billed is not supported by the provided medical records. 
 
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 A41.9 - 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 the provided documentation described the enrollee as "not septic." Workup 
revealed stable vitals, normal platelets, normal bilirubin, Cr 2.36, and was alert and oriented without oliguria. 
The Sepsis 3 criteria was not met as there was not a rise of 2 or more Sequential Organ Failure Assessment 
(SOFA) points without sufficient evidence of a dysregulated response leading to organ failure. Therefore, the 
code, A41.9 (sepsis) is not supported in the documentation for this admission.   
 
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 September 28, 2022, to October 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.