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 these services are medically necessary for you. The 
Plan denied your request. The Plan says you can receive care in an alternate setting.  
 
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 you do not require an IRF admission to recover function following an uncomplicated 
hip fracture repair per evidence-based and well established clinical practice standards.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinary tract infection panel provided on  
November 10, 2022. 
 
You asked the Plan to pay for the urinary tract infection panel. You say that the urinary tract infection panel 
was medically necessary. The Plan denied your request. The Plan says the urinary tract infection panel was 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 pay for the urinary tract infection panel. Our reviewer says that the requested urinary tract infection panel is not considered medically reasonable and 
necessary. Our physician reviewer found a review of the medical literature in clinical practice guidelines, 
including by the Infectious Disease Society of America and Healthcare Infection Control Practices Advisory 
Committee (HICPAC), state that standard of care for evaluation of urinary tract infection includes a urinalysis, 
followed by a urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility 
of large multiplex polymerase chain reaction (PCR) urinary tract infection panel tests. Urine PCR amplification 
techniques raise considerable concerns regarding contamination from one specimen to another, creating the 
potential for false-positive results. The clinical interpretation of PCR results may also be challenging. 
Amplification of organisms representing latent infection or colonization cannot be distinguished from active, 
clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead 
microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and 
positive and negative predictive values of PCR have not been reported in large groups of patients for many of 
the microorganisms. 
 
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 urinary tract infection panel have not been met. Therefore, we decided that 
the Plan does not have to pay for a urinary tract infection panel provided on November 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427-NH, A0425-NH) provided on 
January 9, 2023. 
 
You asked the Plan to pay for ambulance services. You say that this claim still needs to be processed by the 
Medicaid portion of this dual plan. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 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 February 1, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0427-NH, A0425-NH) 
provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the equipment is needed for chronic 
respiratory failure and severe kyphoscoliosis. The Plan denied your request. The Plan says a home ventilator is 
not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide 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 pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the patient 
has not had failure with a BiPAP or a BiPAP with AVAPS. The patient has also tolerated the intervention with 
a BiPAP while in the hospital. Therefore, there is no indication that the patient is currently requiring a home 
ventilator. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36556 and 76937 rendered on April 24, 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 the records do not support the services 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
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 the documentation supports that the 
services in question were rendered and appropriately coded. There is satisfactory documentation that a central 
line was placed via the internal jugular vein. There is satisfactory documentation that the line was placed 
centrally. As most central lines placed in the intensive care unit/emergency room floor are not placed under 
fluoroscopic guidance, the exact location of the tip cannot be documented, and it is not reasonable to require 
this information to justify billing. Therefore, CPT 36556 is supported. 
 
In terms of CPT 76937, this codes for ultrasound guidance for vascular access. There is satisfactory 
documentation that ultrasound guidance was used to access a patent jugular vein.  While there is a stipulation 
that the images must be archived, it is not reasonable to require documentation of this in the operative note. 
 
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 
procedure codes 36556 and 76937 rendered on April 24, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on April 13, 2023, 
and billed with codes 87653, 87651, 87640, 87556, and 87481. 
 
You asked the Plan to pay for the urinary tract infection panel. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urinary tract infection panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel 
provided on April 13, 2023, and billed with codes 87653, 87651, 87640, 87556, and 87481.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 97112, 97116, and 97530 provided on February 10, 
2023. 
 
You asked the Plan to pay for procedure codes 97112, 97116, and 97530. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure codes 97112, 97116, and 97530 based on Medicare criteria. Medicare rules say 
documentation requirements for therapy services indicates that the amount of time for each specific 
intervention/modality provided to the patient is not required to be documented in the Treatment Note. 
However, the total number of timed minutes must be documented. The medical record clearly shows the total 
number of timed minutes correctly. Therefore, we decided that the Plan has to pay for procedure codes 97112, 
97116, and 97530 provided on February 10, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting.  
 
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 does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the enrollee 
require treatment by multiple therapies and there is a reasonable expectation that you would be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF, the services 
required can be provided at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2023, to May 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2023, to May 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens, scleral, gas permeable, per lens provided on 
March 28, 2023. 
 
You asked the Plan to pay for the contact lens, scleral, gas permeable, per lens. You say that a claim with the 
same procedure and diagnosis was paid in 2022. The Plan denied your request. The Plan says the diagnosis on 
the claim does not indicate that the patient has undergone surgical removal or has congenital absence of the 
lens of the eye. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the contact lens, scleral, gas 
permeable, per lens have been met. Specifically, no medical records were provided for our review. Therefore, 
we decided that the Plan does not have to pay for contact lens, scleral, gas permeable, per lens provided on 
March 28, 2023.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the current clinical 
information does not support the medical necessity criteria for LTACH placement. 
 
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 you are improving but still require acute care services before transitioning to a 
lower level of care. You continue to receive acute care services and these have not been denied. The medical 
record does not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zenith amniotic membrane from December 7, 2022, to 
January 11, 2023. 
 
You asked the Plan to pay for Zenith amniotic membrane. You say that the product was medically necessary. 
The Plan denied your request. The Plan says that Zenith is considered investigational. 
 
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 Zenith amniotic membrane. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical documentation shows that the enrollee presented with complaints of 
a one-year ulceration to the lateral aspect of the left ankle. During that time, no formal wound debridement was 
noted. The enrollee advised that they used Medihoney and Band-Aids. Shortly after the first initial wound evaluation, a Zenith allograft was applied to the wound. Medicare guidelines advise that they will pay for items 
or services that are reasonable or necessary to improve the functioning of a malformed body member. This 
must be safe and effective, not mainly for the convenience of the enrollee or the physician, not experimental or 
investigational, appropriate in that it is furnished in accordance with accepted standards of medical practice for 
the diagnosis or treatment of the enrollees condition, one that meets but does not exceed the enrollees medical 
needs, and at least as beneficial as an existing and available medically appropriate alternative. In this particular 
case, at the time of the Zenith allograft application, it did not appear that the enrollee had undergone formalized 
wound care including sharp debridement, advanced wound dressings, and offloading the area. It appears that 
that situation did not meet the Medicare guidelines of being performed in accordance with accepted standards 
of medical practice, and a treatment that meets but does not exceed the enrollees medical 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 Zenith amniotic membrane have not been met. Therefore, we decided that the 
Plan does not have to pay for Zenith amniotic membrane from December 7, 2022, to January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a major fall risk and and very likely to 
further injure themself. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval.  
 
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 enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does 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 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 this 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.