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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 11, 2022, 
to August 12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not medically necessary. 
 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 underwent a procedure, which is not on the inpatient only list and is not 
expected to require two midnights of inpatient level care.  There is no documentation of uncontrolled co-
morbidities pre-procedure, and no documentation of procedural/post-procedure complications, which 
necessitated a prolonged (i.e., two midnight) stay. The enrollee presented, underwent the procedure, was 
monitored and was discharged, spending only one midnight in the hospital. Therefore, the services rendered 
were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 August 11, 2022, to August 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that Imfinzi 
is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo carotid sinus baroreflex device. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this is medically necessary due to the 
enrollee's medical history. The Plan denied your request. The Plan says this device 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 Barostim Neo device. Our reviewer 
says that the requested Barostim Neo device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this patients 
clinical management. Therefore, the reviewer found that the requested Barostim Neo device is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo carotid sinus baroreflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hernia surgery provided on January 10, 
2023. 
 
You asked the Plan to waive the copayment for the hernia surgery. You say that since this was a repeat of a 
previous surgery you should not have to pay. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery. 
 
You have been asked to pay a $200 copayment for the hernia surgery. This item/service falls within the 
outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hernia surgery 
provided on January 10, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from July 28, 2022, to August 25, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the reported diagnosis codes are not supported by the 
provided medical records. 
 
The Plan follows Medicare rules. Medicare rules say that the patients primary diagnosis is defined as the chief 
reason the patient is receiving home care and the diagnosis most related to the current home health Plan of 
Care. 
 
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 home health services. Our reviewer says that 
home health services meet criteria for payment as billed. Our physician reviewer found that the available 
clinical documentation shows that the diagnosis codes reported on the claim were supported and signed by 
attending physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pay for home health services provided from July 28, 2022, to August 25, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment for Vitiligo.  
 
You asked the Plan to pre-approve laser treatment for Vitiligo. You say that laser treatment for Vitiligo is 
medically necessary. The Plan denied your request. The Plan says that laser treatment for inflammatory skin 
disease is not covered under your current plan for the treatment of Vitiligo. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 laser treatment for Vitiligo. Our 
reviewer says that the requested laser treatment for Vitiligo is considered medically reasonable and necessary 
in this case. Our physician reviewer found that excimer laser phototherapy is a standard of care for vitiligo 
unresponsive to topical medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser treatment for Vitiligo have been met. Therefore, we decided that the Plan 
has to pre-approve laser treatment for Vitiligo.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip replacement surgery (arthroplasty) and associated 
procedure with an out-of-network provider. 
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee has a history of lower-level 
multi-lumbar spine fusion which would increase complexity and required the need for consideration of 
modification of the acetabulum and consideration of dual mobility liner intraoperatively. You also say that the 
enrollee has a spinal cord stimulator. The Plan denied your request. The Plan says the procedure can be 
performed in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical services. Our reviewer says 
that the request for a hip replacement to be provided by an out-of-network orthopedic surgeon is not medically 
necessary. Our physician reviewer found detailed documentation is not evident regarding anything particularly 
unique about the enrollees condition that would make it medically necessary for them to see the requested out-
of-network provider. The Plan has provided an in-network orthopedic surgeon for this enrollee to seek 
treatment with. Therefore, the Plans denial is medically justified on the basis that it is offering adequate care to 
meet the enrollees medical needs through referral to an in-network orthopedic surgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a hip replacement surgery (arthroplasty) and associated procedure with an out-of-
network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has neurogenerative changes and 
measurement of the cerebral glucose metabolism has significant value and facilitates early diagnosis. 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 the record indicates that the enrollee has 
memory loss with a normal mini-mental state examination (MMSE) examination. The record provided does not 
establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal 
dementia or that the examination is being requested in the context of a clinical trial. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 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 positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for seven additional units of procedure code 77331 rendered on May 8, 
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 that while the documentation does support that excess units were provided, there was no specific 
rationale given for why the additional units needed to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 77331 is "Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating 
physician." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that in general, code 77331 reflects 
special dosimetry used to report a measurement of radiation dose at a given point on (or less commonly in) the 
patient, using special radiation monitoring and measuring devices such as thermoluminescent dosimeters 
(TLDs), solid state diodes or other means.  This is a quality assurance measure used to check the dosimetry at a 
point in a treatment port and is used to either accept or revise the treatment plan. It is not always necessarily 
required to do this for every field but may be useful to perform measurements on select points on the patient. 
Total skin electron therapy is a complex treatment requiring multiple beams to treat an uneven surface, with 
attempts to make the dose somewhat homogeneous. It would be fairly standard to use a solid state 
microdosimeter to confirm accurate dose delivery, and this would need to be performed on several sites over 
the skin. The records document this being done for 10 dose calculations, and this service is plausibly needed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
seven additional units of procedure code 77331 rendered on May 8, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code I69.351 
rendered from August 24, 2022, to August 27, 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 one or more of the billing diagnoses were not 
supported by the clinical records and/or did not impact the clinical resource utilization. 
 
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 diagnosis code I69.351. 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 enrollee had facial numbness, per the documentation. However, this does not qualify as 
hemiplegia or hemiparesis. Therefore, diagnosis code I69.351 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 billed with diagnosis code I69.351 rendered from August 24, 2022, to August 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation air- pulse 
generator system (HFCWO) (E0483). 
 
You asked the Plan to pre-approve a HFCWO. You say that the item is medically necessary. The Plan denied 
your request. The Plan says records do not show cystic fibrosis, bronchiectasis, or a neuromuscular disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation air- pulse generator system (HFCWO) (E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home mechanical ventilator (E0466). 
 
You asked the Plan to pay for the home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide continuous 
positive airway pressure (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 pay for the home mechanical ventilator. Our 
reviewer says that the enrollee does not need this item. Our physician reviewer found the enrollee could be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented 
 
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 home mechanical ventilator have not been met. Therefore, we decided that 
the Plan does not have to pay for the home mechanical ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test (HST) (G0399). 
 
You asked the Plan to pre-approve an HST. The Plan denied your request. The Plan says this request has been 
denied because the clinical information provided does not indicate that the enrollee has observed apneas 
(stopped breathing), choking or gasping during sleep, and a completed and abnormal score on the Epworth 
Sleepiness Scale. 
 The Plan follows Medicare rules. Medicare rules say that for a diagnosis of obstructive sleep apnea (OSA) to 
be made, the criteria listed in the Medicare rules section of this letter must be 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 an HST. Our reviewer says that an 
unattended sleep study is not medically necessary. Our physician reviewer found this enrollee was evaluated on 
June 7, 2023, for swelling of the uvula and hoarseness. The enrollee reported moderate snoring and daytime 
sleepiness. However, the Epworth score was 0. Our reviewer found that the Body Mass Index (BMI) was 28.1, 
and the neck circumference was 15. There was no history of choking at night, disruptive snoring, non-
restorative sleep, witnessed apneas, or hypertension. Our physician reviewer also found that the medical 
symptoms and findings do not support a strong suspicion for OSA, according to Medicare criteria. 
 
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 HST have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a home sleep test (HST) (G0399).