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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for IRF admission. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for approval of IRF 
services.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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 the requested IRF services are necessary because you 
are on oxygen and take antibiotics daily due to kidney failure. You also say you are weak and cannot walk far 
distances. The Plan denied your request. The Plan says the notes do not show that your care specifically 
requires the involvement of a doctor in the field of Rehabilitation Medicine. The notes do not show that you 
have complex care needs that require a coordinated team approach. The notes do not show that you must have 
an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-care functioning.  
 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. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at 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. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It 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 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 power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and accessories 
(E0955, E1002, E1028, E2310, E2363, E2607, E2620). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee requires a 
minimum of 35-40 degrees of tilting to achieve effective pressure release. The wheelchair and accessories are 
medically necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of the requested wheelchair and accessories. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
Parkinson's disease. He has experienced a fall when his walker caught on a door threshold. He had a slide out 
of bed fall when rising to urinate. He is able to stand and does not have impaired skin. Per L33789, the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and accessories (E0955, 
E1002, E1028, E2310, E2363, E2607, E2620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 rendered on July 25, 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 Current Procedural Terminology (CPT) code 99308-25 (1 units) remains not supported. 
 
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 99308 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using total time on the date of the encounter for code 
selection, 15 minutes must be met or exceeded." 
 
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 CPT code 99308-25 is not 
supported as a separately identifiable procedure. The documentation submitted pertains to the wound care and 
debridement; no separate evaluation and management was performed. 
 
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 procedure code 99308 rendered on July 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (64555). 
 
You asked the Plan to pre-approve a Sprint peripheral nerve stimulator (PNS). You say that you are requesting 
reconsideration stating the enrollee is in extreme pain and this procedure is his only chance for relief from his 
pain. The Plan denied your request. The Plan says the Sprint PNS system does not meet the Medicare criteria as 
it is not an implanted peripheral neurostimulator with a trial of implantation showing effective pain control. 
 
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 Sprint peripheral nerve stimulator 
(PNS). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has pain in his leg after saphenous vein 
harvesting for coronary artery bypass graft (CABG). His medication trials have included Gabapentin, opiates, 
and duloxetine. This is considered experimental/ investigational therapy for a saphenous nerve injury. 
Therefore, the request is deemed not medically 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 Sprint peripheral nerve stimulator (PNS) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (64555).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code H0015. 
 
You asked the Plan to pre-approve procedure code H0015. You say that the services were billed correctly. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H0015 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0015 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0015 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code H0015.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 3, 2023, to 
February 7, 2023, 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 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 E11.10, described as type 
2 diabetes mellitus with ketoacidosis without coma, and secondary diagnosis code G93.41, described as 
metabolic encephalopathy. 
 
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 was diagnosed with diabetes, but there was no evidence of ketoacidosis by 
documentation, so code E11.10 is not justified. There is not clear evidence of metabolic encephalopathy, so 
code G93.41 is not justified.  
 
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 3, 2023, to February 7, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of the enrollee's condition. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental in spine surgery. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the request is medically necessary. The 
Plan denied your request. The Plan says the request 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 genicular nerve blocks. 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/investigational therapy and is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discarded drug amounts described by code Q5118-JW 
billed for dates of service May 8, 2023, and May 22, 2023.  
 
You asked the Plan to pay for Q5118-JW. You say that Q5118-JW should be paid as billed because it is coded 
correctly and supported in the medical record. The Plan denied your request. The Plan says Q5118-JW is denied because the medical record provided does not document the discarded drug amount for the dates of 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that when billing for 
appropriately discarded drugs or biologicals using modifier -JW, providers are required to document the 
discarded drug amount in the medical record. 
 
In this case, the CPT Code Manual definition of code Q5118-JW is discarded units of injection, bevacizumab-
bvzr, biosimilar, (zirabev), 10 milligrams (mg). 
 
We find that CPT code Q5118-JW is not supported in the medical record. Specifically, we have confirmed that 
the record does not contain documentation of discarded units of the drug described by code Q5118 on the billed 
dates of service May 8, 2023, and May 22, 2023. According to Medicare rules, in order for discarded units of 
drugs or biologicals to be covered, the discarded amounts must be documented in the medical record and billed 
with modifier -JW. Therefore, Q5118-JW is not supported in the record. Based on this information, we decided 
that Medicare rules for coverage of Q5118-JW have not been met. Therefore, we decided that the Plan does not 
have to pay for the discarded drug amounts described by code Q5118-JW billed for dates of service May 8, 
2023, and May 22, 2023.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pay for the heating pad. We decided that the Plan does not have to pay for the 
medication.  
 
You asked the Plan to pay for the medication and heating pad purchased on May 12, 2023. You say that you do 
not understand why the claim was denied in the first place, because you sent in a print out of the doctor's 
credentials and the receipt. The Plan says that the medicine used for the injection is a service under the 
Medicare Part D benefits. Medicare Part D excludes medications purchased outside of the Unites States. The 
Plan also says in addition, the purchase of the heating pad does not meet the criteria to be considered Durable 
Medical Equipment, and cannot be approved. 
 
We decided that the Plan has to pay for the heating pad.  
 
The Plan follows Medicare rules. Medicare rules say that a standard electric heating pad is covered to relieve 
certain types of pain, decrease joint and soft tissue stiffness, relax muscles, or reduce inflammation. The rules 
also say that a heating pad is not reasonable and necessary to treat pain due to peripheral neuropathy. 
 
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 item/service at issue. Our reviewer says 
that the heating pad was medically necessary. Our physician reviewer found the heating pad was provided due 
to an unforeseen flare up of back pain, so application of a heating pad is therapeutically effective. It was used 
to relieve pain and relax muscles. Our reviewer also found that it was not being used to treat pain due to 
peripheral neuropathy.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for the heating pad.  
 
 
 We also decided that the Plan does not have to pay for the medication. 
 
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 the medication. 
 
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 laboratory testing provided on February 14, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the documentation submitted does not include a valid physician order for 
the specific test codes billed on this claim. 
 The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be 
specifically ordered by the physician who is treating the enrollee.  
 
We looked at the file and Medicare rules. The lab codes billed on this claim are not supported by an order from 
the enrollees treating physician. Specifically, although a lab order was submitted the order form requests a 
proprietary test panel without specification to support the codes billed on the claim. Based on this information, 
we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Basaglar KwikPen. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
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 pre-approve Basaglar KwikPen.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.