Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs to have fixed tidal 
volume ventilation with some daytime usage to help with severe restriction and chronic hypercapnia. Without 
the use of NLV, the enrollee will be at risk for costly procedures, hospital readmission and other complication 
due to her chronic respiratory failure. The NIV will improve her quality of life. The Plan denied your request. 
The Plan says that the request for a non-invasive ventilator (NIV) is not medically necessary because the 
documentation does not support that the use of a CPAP or BiPAP device would not meet the enrollee's medical 
needs and there is no documentation that BiPAP with AVAPS has been found to be ineffective. 
 
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 home ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee has very severe thoracic 
restrictive disease related to thoracic kyphosis and scoliosis. Recent pulmonary function testing showed an 
FEV1 of 41% of predicted and a total lung capacity of 32% of predicted. Severe deformity of the chest is 
confirmed on chest CT scan. A recent ABG, done when the enrollee presented with neck pain but no 
respiratory distress, was consistent with chronic CO2 retention. This enrollee would benefit from ventilatory 
support during sleep and as tolerated during the day. Sip and puff ventilation during the day may be of benefit. 
The severity of the enrollee's restriction is such that battery backup and alarms are considered reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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 provided on September 12, 2022, 
to September 19, 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 is billed correctly. The Plan denied your request. The Plan says principal diagnosis code A41.89 is 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 A41.89 - other specified sepsis. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found the Health Plans denial should be upheld. The enrollee presented with a known 
foot ulcer and fever, in the setting of diabetes and renal transplant. While there was initial concern for possible 
sepsis, there is no evidence that the enrollee had systemic illness, hemodynamic instability or organ failure. As 
such, the billing of A41.89 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 September 12, 2022, to September 19, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee's 
mobility, strength, and amount of help you needed to do daily activities has been stable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found skilled services are not necessary for your functional status to improve and  you dop 
not have daily skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPECT scan of radiopharmaceutical localization of 
tumor. 
 
You asked the Plan to pre-approve a SPECT scan of radiopharmaceutical localization of tumor. You say that 
the enrollee would like reconsideration because the services are medically necessary. The Plan denied your 
request. The Plan says a SPECT scan of radiopharmaceutical localization of tumor is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a SPECT scan of radiopharmaceutical 
localization of tumor. Our reviewer says that a SPECT scan of radiopharmaceutical localization of tumor is not 
medically necessary. Our physician reviewer found that there is no evidence of ATTR (amyloid transthyretin) 
and no clinical evidence to support the performance of the SPECT imaging for the enrollee according to current 
guidelines. As a result, at this time SPECT imaging would not be considered medically reasonable and 
necessary in the enrollee's clinical management. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SPECT scan of radiopharmaceutical localization of tumor. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a SPECT scan of radiopharmaceutical 
localization of tumor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head or brain. 
 
You asked the Plan to pre-approve a CT scan of the head or brain. You say that the CT scan of the head or 
brain is being requested due to the enrollee showing signs of being confused as well as being forgetful. The 
Plan denied your request. The Plan says a CT scan of the head or brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the head or brain. Our 
reviewer says that a CT scan of the head or brain is not medically necessary. Our physician reviewer found that 
during the encounter on February 2, 2023, the enrollee showed signs of confusion. Although the enrollee has 
not been evaluated since February 2, 2023, there is no history of trauma, cognitive testing, and negative 
neurological evaluation. Therefore, medical necessity of the requested CT scan was not established in the 
submitted records. 
 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 CT scan of the head or brain have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the head or brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on December 27, 2022. 
 You asked the Plan to pay for an electrocardiogram. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an electrocardiogram provided on December 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the medical records provided support the need for 
SNF care. The Plan denied your request. The Plan says your records do not show that you require daily skilled 
nursing or skilled therapy in a SNF setting. The Plan says that the services you require are called custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 13, 2023, 
through January 25, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that that you were in the hospital when you 
were given medications to help your blood pressure. The Plan denied your request. The Plan says self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from January 13, 2023, through January 25, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (procedure codes L1686 and L2624) provided on 
November 8, 2022. 
 
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 there is evidence of misrepresented services. 
 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 there is no clear documentation available for review that supports that the enrollee has significant 
hip joint pain or any abnormal physical findings that would necessitate treatment with an orthosis. The 
requested orthosis does not appear appropriate to the enrollees medical needs and condition. 
 
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 orthotics (procedure codes L1686 and L2624) provided on November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 31, 2021, to 
April 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says principal diagnosis J96.11 and secondary 
diagnosis I13.0 are 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 J96.11 - chronic respiratory failure with hypoxia 
and I13.0 - hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic 
kidney disease, or unspecified chronic kidney disease. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pay for the inpatient hospital services at the DRG originally billed. Our physician reviewer found the Health 
Plans denial should be upheld. The enrollee presented with altered mental status, falls, chest pain and 
shortness of breath. The shortness of breath was multifactorial but was mainly and routinely attributed to acute-
on-chronic heart failure. The enrollee was secondarily evaluated for their tremors/falls and maintained on the 
enrollee's oxygen for the enrollee's chronic obstructive pulmonary disease (COPD). The ordering of diagnoses 
is not supported (J96.11 before I13.0).  
 
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 March 31, 2021, to April 7, 2021, 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 subsequent hospital care (procedure code 99233) rendered on 
May 12, 2021. 
 
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 this service is not supported without the required documentation. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99233. The documentation available for review does not support the enrollee 
developed a significant complication or that medical decision making of high complexity was 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 not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on May 12, 2021.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical, needs (combined complexity) does not require 
an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation 
needs can be provided in a lower intensity and alternate setting such as in a skilled nursing facility (SNF). 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the enrollee is having symptoms 
such as lower back and right should pain for the last 10 years. The Plan denied your request. The Plan says an 
MRI of the lumbar spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
the enrollee was neurologically intact during an encounter on March 28, 2023. There were no plain film results, 
red flags or conservative therapy including physical therapy. A Medrol dose pack was given but there was no 
follow up to analyst the results. Therefore, the medical necessity of the requested MRI of the lumbar spine has 
not been established in the provided records. 
 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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine.