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 February 1, 2022, to 
February 8, 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 A41.02, described as 
sepsis due to Methicillin resistant Staphylococcus aureus. 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 documentation describes the patient as presenting 
with fever, nausea, vomiting, and change in mental status, diagnosed with possible wound infection and urinary 
tract infection. Blood pressure was stable, he was tolerating room air without respiratory distress, platelets were 
normal, creatinine was 1.03, bilirubin was normal, and he was alert and oriented x 2. Glasgow Coma Scale was 
15 following initial treatment with fluids and antibiotics. Sepsis 3 criteria were not met as there was insufficient 
evidence of organ failure directly related to a dysregulated response to systemic infection. Therefore, the code, 
A41.02 (Sepsis) is not supported in the documentation.   
 
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 February 1, 2022, to February 8, 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 a Prostate Artery Embolization (PAE). 
 
You asked the Plan to pre-approve a Prostate Artery Embolization. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 Prostate Artery Embolization. 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. 
 
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 Prostate Artery Embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Prostate Artery Embolization (PAE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93321 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for procedure code 93321. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93321 is bundled into 
payment for code 33361. 
 
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, we have confirmed that code 93321 
is a column II code to column I code 33361. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 93321 billed for date of service February 14, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that if the enrollee is unable to have access to the 
PET scan, the plan of care will be interrupted.  The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records provided for review did 
not support that the enrollee met diagnostic criteria for either Alzheimers disease or frontotemporal dementia 
let alone both conditions. The base requirement for coverage of the requested service would not have been 
met/satisfied.  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 25, 2022, to 
January 27, 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 codes. 
 
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, and secondary diagnosis code J96.01, described as acute respiratory failure with 
hypoxia. 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 codes. Our physician 
reviewer found that the enrollee is an 82-year-old male who was treated in the hospital. He presented with 
fatigue and shortness of breath. Workup revealed normal white blood cell count, bilirubin, blood pressure, and 
oxygen saturation on room air, but chest X-ray revealed signs of pneumonia. Platelets were slightly low at 144, 
and creatinine was 1.29, but without oliguria. He was alert and oriented x 3. He was treated with fluids, 
antibiotics, bronchodilators, and low dose oxygen support only. Following initial treatment, creatinine returned 
to normal. Based on the above, the thrombocytopenia is the only SOFA point rise and not sufficient to meet 
Sepsis criteria. Also, the enrollee did not require high flow oxygen, bilevel positive airway pressure, or vent 
support and did not have significant acute respiratory distress. Therefore, the codes, A41.9 (sepsis) and 
secondary diagnosis J96.01 (acute respiratory failure) are each not supported in the documentation.   
 
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 January 25, 2022, to January 27, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the reports support the level of service. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 4, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed services were provided twice on the same date.  
 Based on this information, we decided that the Medicare rules for the billed services have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for date of service 
November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown tooth #31 
(D2750). 
 
You asked the Plan to pre-approve a crown. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary because the x-rays of your tooth must show 
your tooth has to have a lot of tooth missing from a cavity or has a lot of damage from being broken. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the radiographs provided were not of diagnostic quality, therefore it could not be determined if a crown restoration was warranted for tooth #31. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve white glass with high gold content crown tooth #31 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 8, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that you should be paid for this service. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluid jet system treatment. 
 
You asked the Plan to pre-approve fluid jet system treatment. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 The Plan follows Medicare rules. Medicare rules state that fluid jet system treatment is only covered if certain 
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 fluid jet system treatment. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the records do not 
show an International Prostate Symptom System (IPSS) of 12 or greater or a maximum urinary flow rate 
(Qmax) of 15 or less. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fluid jet system treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve fluid jet system treatment.
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 currently meets the LTACH 
criteria for admission. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements. Services needed may be provided safely in a lower level of 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a bridge (D6740, D6245). 
 
You asked the Plan to pre-approve a bridge. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a clinical review of the documentation submitted for this claim determined the 
service does not meet the criteria for coverage. 
 
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. The Plan covers a bridge when 
the services are medically necessary and reasonable. 
 
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 bridge. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the criteria for fixed bridgework has been met 
subject to the yearly maximum coverage.  The support of the abutment teeth appear adequate and adequate 
masticatory function would be achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a bridge have been met. Therefore, we decided that the Plan has to pre-approve 
a bridge (D6740, D6245).  
 
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 pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says an IRF level of care is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the enrollee 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 an IRF admission and services.
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 physiatrist oversight or interdisciplinary rehabilitation. 
 
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: 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 have a fractured hip, and no surgery can be done 
to fix it stated that rehab is the only option. The Plan denied your request. The Plan says your records do not 
show that your rehab needs are complex and that you need to be seen 3 times per week for evaluation of 
functional and medical goals and progress. 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 your 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary to help 
with the enrollee's diabetes. The Plan denied your request. The Plan says the enrollee is not receiving insulin 
and they have not had any documented hypoglycemic episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
Medicare criteria was not met. Our physician reviewer found that there is no mention in the office note given 
that the enrollee uses insulin or has low blood glucose sugars. The enrollee is on medications that do not 
usually cause low blood glucose sugars in the level 2 range. Although the form indicates by a check in the yes 
box that the enrollee uses insulin, this does not match with the office note. If additional information is available 
to suggest that the enrollee uses insulin this should be submitted and the case re-reviewed; based on the 
provided medical notes, criterion 4 is not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).