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

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 871 rendered 
from October 7, 2022, to October 11, 2022. 
 
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 DRG was revised from 871 to 641. 
 
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 871. 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 there was insufficient evidence of a systemic infection present or a dysregulated response to such causing 
organ failure. Therefore, diagnosis code A41.9 is not supported. Also, diagnosis code G93.41 was not 
sufficiently supported as the enrollee was at her baseline mental status without evidence of encephalopathy 
present. DRG 641 is more appropriate 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 reported with DRG 871 rendered from October 7, 2022, to October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the MyoPro device is safe and effective. The 
Plan denied your request. The Plan says there are not enough studies to show MyoPro is safe and effective to 
help the enrollee recover from his disability. 
 
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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iris prosthesis. 
 
You asked the Plan to pre-approve an iris prosthesis. You say that the enrollee has little to no iris tissue and is 
an ideal candidate for the iris prosthesis. The Plan denied your request. The Plan says the requested iris 
prosthesis is considered experimental and investigational. 
 
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 an iris prosthesis. Our reviewer says 
that the requested iris prosthesis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found evidence in the peer reviewed scientific literature evaluating use of the artificial iris 
prosthesis has not firmly established safety and efficacy of the device. Professional society statements 
regarding use of the device as treatment for aniridia from the American Academy of Ophthalmology and American Association for Pediatric Ophthalmology were not found. Within the clinical studies several authors 
have reported high complications rates, both intra and post-operatively. As a result, strong evidence-based 
conclusions regarding safety and efficacy cannot be made. Additional clinical studies with longer follow-up are 
needed to evaluate use of the device and impact on health outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an iris prosthesis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an iris prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 193 rendered 
from January 13, 2023, to January 20, 2023. 
 
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 has determined that the billed 
services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 193. 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 evaluation revealed the patient with 88% SpO2 with exertion and 95% SpO2 on 4L/m nc in the 
emergency department. It was noted that the patient was not in respiratory distress. No arterial blood gases 
were noted. There was no accessory muscle use with breathing, and no additional hypoxia, need for high flow 
oxygen support (except for comfort only after ambulation), bilevel positive airway pressure (BiPAP), or vent 
support after admission. Therefore, the code, J96.01 (acute respiratory failure with hypoxia) is not sufficiently 
supported for this admission. Therefore, DRG 194 is 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 reported with DRG 193 rendered from January 13, 2023, to January 20, 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 enrollee's representative is appealing the denial 
of the requested inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for cellulitis, sepsis, and atrial fibrillation. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. The patient 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 and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that while other devices can provide a similar mode called 
average volume-assured pressure support (AVAPS), they are not equipped with the same pressure and flow 
ranges or features necessary for the enrollee's need of advanced ventilation. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with AVAPS. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the NIV. Our reviewer says that the 
NIV is not shown to be medically necessary in this case. Our physician reviewer found the records do not show 
evidence for a diagnosis of neuromuscular disease or thoracic restrictive disease. This patient may benefit from 
BiPAP with AVAPS during sleep as an outpatient. The records do not show this has been tried as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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 NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
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 the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH services.  The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for LTACH services.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation provided does not support that LTACH services are medically 
appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88377 and G0452 rendered on April 24, 
2023. 
 
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 these codes cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
laboratory report does not include documentation to support the rationale for separate billing with modifier -59. 
The codes cannot be verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 88377 and G0452 rendered on April 24, 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 enrollee's treating physician is appealing the 
denial of the requested inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this 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.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is currently receiving medically necessary 
care.  
 
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 that the acute hospital can provide for all the patients present inpatient care needs 
and the patient is receiving an appropriate level of care in the present setting. The provided records do not 
explain what care services will be provided in the LTACH that are not available in the present hospital setting. the acute hospital can provide for all the patients present inpatient care needs and the health plan has stated 
that continued care in the short-term acute hospital will be covered as is medically indicated. The patient is 
presently receiving appropriate services in the acute care setting. The provided records do not support the need 
to transfer from one acute hospital to another. Continued care in the short-term acute hospital is appropriate 
until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-
acute rehabilitation facility or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital admission and care provided from 
November 26, 2022, to November 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's conditions were not 
properly reviewed in making this denial decision. The Plan denied your request. The Plan says the submitted 
documentation supports the observation level of care. 
 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 the enrollee is an 80-year-old female who presented to the emergency department 
(ED) with abdominal pain and constipation in the setting of recent chemotherapy for metastatic breast cancer. 
Computed tomography showed large stool and stercoral colitis. She was started on a bowel regimen and passed 
bowel movements without complication and tolerated oral mediation transition. She was discharged home one 
day after admission. Based on the low complexity and stability of the clinical situation, it was not expected that 
the patient would have required hospital care that would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital admission and care provided from November 26, 2022, to 
November 27, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Infed (iron dextran) and Venofer (iron sucrose) would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve the crown. You say that the records provided support the need for the  The 
Plan denied your request. The Plan says their records show that the enrollee has already had this service done 
within the last 5 years, and that the benefit for this service is exhausted.  
 
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 benefit for the requested service is limited to once per tooth, every 5 calendar years. The records show that the enrollee received coverage for a 
porcelain/ceramic crown on tooth #31 on July 15, 2022. This means it has been less than 5 years since this code 
was paid for tooth #31. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic 
crown (D2740) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) provided on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your annual dental allowance amount has already been exhausted. 
 
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 your annual dental allowance amount was exhausted on date of service April 14, 2023. Therefore, we 
decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110/D5120) 
provided on May 23, 2023.