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

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 9, 2022 to 
August 16, 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 this 
service was medically necessary. The Plan denied your request. The Plan says the documentation does not 
support the DRG billed. 
 
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 853. 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 records do not support the DRG billed. Our physician reviewer found there is no evidence that the 
enrollee had hypoperfusion or organ failure.  As such, the billing of  diagnosis code A41.9 is not supported.  
 
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 August 9, 2022 to August 16, 2022, 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 April 15, 2022, to 
April 21, 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 the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described 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 documentation does not support the billed code. 
Our physician reviewer found the enrollee was treated for possible pneumonia and acute-on-chronic heart 
failure. There is no evidence that the enrollee had hypotension, hypoperfusion or organ failure related to his 
pneumonia. As such, a diagnosis of sepsis is not supported.  
 
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 15, 2022, to April 21, 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 Interspinous process distraction devices. 
 
You asked the Plan to pre-approve Interspinous process distraction devices. You say that pain is greatly 
affecting the enrollee's health. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
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 Interspinous process distraction 
devices. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found Interspinous process distraction devices are experimental, 
and more research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Interspinous process distraction devices have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Interspinous process distraction devices.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (80307) provided on July 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that only one drug test 
is reportable per date of service, and the physician office already billed 80305 prior to the receipt of this claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that only one drug test is reportable per date of service, and the 
physician office already billed 80305 prior to the receipt of this claim. However, the Plan has not provided 
documentation showing that another presumptive drug test was billed and paid for the date of service in 
question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the drug testing services (80307) provided on July 22, 2021.  
 
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 power wheelchair with multiple power 
options, and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee needs the requested wheelchair. The Plan denied your request. The Plan says the enrollee does not 
have a qualifying diagnosis causing mobility limitation for which group 3 power wheelchair is medically 
needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options, and accessories.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99213) and psychotherapy (90833), provided on 
January 26, 2023. 
 
You asked the Plan to pay for the office visit and psychotherapy. You say that the services should be covered. 
The Plan denied your request. The Plan says that this is not a covered benefit or exceeds the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is no indication of why the Plan denied this claim or what rules they 
followed for the denial. Therefore, we decided that the Plan has to pay for the office visit (99213) and 
psychotherapy (90833), provided on January 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GuardantReveal test rendered on September 20, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this test does not have Food and Drug Administration (FDA) or MolDx approval. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this testing is not FDA-approved or cleared for use in lung adenocarcinoma. 
 
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 the GuardantReveal test rendered on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on January 5, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for oxygen equipment. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for oxygen equipment provided on January 5, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine injection provided on March 9, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that the services at issue have been billed correctly. 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 (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 March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
you want the Plan to approve the service. The Plan denied your request. The Plan says intradiscal procedures 
are not supported by research and are not covered. 
 
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 percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is purely experimental. More research 
is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. A venous blood gas was consistent with acute on chronic hypercarbic respiratory failure, but there is 
no arterial blood gas done while stable to document chronic carbon dioxide (CO2) retention. If that is present, 
the enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service July 26, 
2022, to August 24, 2022. You asked the Plan to pay for the billed services. You say that you proceeded with your normal billing 
procedure. The Plan denied your request. The Plan says the NOA was not received timely.  
 
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 27, 2022. The NOA was not received by the Plan until January 11, 
2023. 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 the home health care billed for 
dates of service July 26, 2022, to August 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Bupivacaine (J3490) provided on February 13, 2023. 
 
You asked the Plan to pay for the Bupivacaine. You say that this drug was used as a medically necessary part 
of the enrollee's treatment. You also say that separate expenses are incurred for this medication. The Plan 
denied your request. The Plan says the surgery procedure has a global surgery value of 000. The Plan also says 
that Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
We looked at the file and Medicare rules. The record shows that the enrollee had an injection procedure for 
sacroiliac joint (27096) performed on February 13, 2023. The MFSDB shows that the postoperative period for 
this code is the day of surgery/procedure. The enrollee received the Bupivacaine (J3490) on February 13, 2023, 
which is the same day the initial procedure was rendered. Therefore, this procedure is bundled as part of the 
global surgical fee because it was reported the same day as the injection procedure for sacroiliac joint (27096). 
Based on this information, we decided that Medicare rules for coverage of the Bupivacaine have not been met. 
Therefore, we decided that the Plan does not have to pay for the Bupivacaine (J3490) provided on February 13, 
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. The Plan denied your request. The Plan says the enrollee does not 
require physician oversight or interdisciplinary rehabilitation. Services needed may be provided safely in a 
lower level of care. 
 
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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteopathic manipulative treatment (98929). 
 
You asked the Plan to pre-approve osteopathic manipulative treatment. You say that osteopathic manipulative 
treatment is a medical necessity for you. The Plan denied your request. The Plan says osteopathic manipulative 
treatment 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 osteopathic manipulative treatment. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that you have both chronic pain syndrome and somatic dysfunction. More 
specific information is required to determine the need for osteopathic manipulative treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteopathic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve osteopathic manipulative treatment (98929).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you were referred to get a walker and a 
wheelchair, but where you live there are stairs. You also say that it is very difficult for you to leave home, and 
when you do go out, you need help to get out of the house or come back in. The Plan denied your request. The 
Plan says a wheelchair ramp is not covered under your health plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp (A9270).