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

We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0304).
You asked the Plan to pre-approve the hospital bed. You say that the enrollee does not meet the medical necessity criteria for the extra heavy-duty hospital bed. The Plan denied your request. The Plan says the enrollee will benefit from a bariatric bed due to her multiple medical conditions.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. 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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the extra heavy duty hospital bed is not medically necessary per the LCD Hospital beds and accessories (L33820) which states that an extra heavy-duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. The enrollee does not meet the criteria for this bed as her weight is 250 pounds.
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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0304).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate level 
of care for this patient. The Plan denied your request. The Plan says that enrollee's current needs are being met 
in the acute setting. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) following surgery for severe esophagitis.  
The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the requested item is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is
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 a Dexcom G6 sensor. Our reviewer
says that the item is not medically necessary. Our physician reviewer found the criteria clearly states that you
must be checking blood glucose levels 4 times per day in order for a CGM to be covered and considered
medically necessary. You are checking 1-2 times per day and we are not given a log to review. Although a
CGM would likely help you check more often and improve your blood glucose control, you do not meet the
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 a Dexcom G6 sensor have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Dexcom G6 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on December 25, 2019. 
 
You asked the Plan to pay for genetic test. You say that you are requesting payment. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed using code 
81479 for date of service December 25, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on December 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface, (E0466).
You asked the Plan to pre-approve the ventilator. You say that please review the attached records carefully, the enrollee will require this therapy for the rest of her life as indicated on the prescription. The Plan denied your request. The Plan says the records do not support the medical necessity required to approve the request home ventilator with non-invasive interfaces.
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 the ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage criteria for a home ventilator are not met. This enrollee was recently hospitalized with acute on chronic hypercapnic respiratory failure. She improved on BiPAP. There is no evidence of BiPAP failure. Medicare does not cover ventilators when used as BiPAP. Specific BiPAP devices are capable of providing the AVAPS-AE mode of support, if needed. A home ventilator is 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 the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface, (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on January 24, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient?s medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for radiology services provided by a 
participating provider on April 9, 2020. 
 
You asked the Plan to waive the deductible for radiology services. You say that you are on a fixed income and 
cannot afford this. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for what is your plan deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category what is your 
plan deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for what is your plan deductible. The total amount you are being asked to pay is $275.70. This cost 
sharing is a contractual obligation that had not been met at the time radiology services was received on April 9, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for radiology services 
provided by a participating provider on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 4, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be placed adjacent to the 
CPT code in the comment/narrative field. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant360 testing provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the records provided should support the 
necessity of the requested service. The Plan denied your request. The Plan says the medical records provided 
do not support the medical necessity criteria. 
 
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 the home ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the coverage criteria for a home ventilator are not met.  This enrollee has obesity-
hypoventilation syndrome, which is not a covered diagnosis for a home ventilator.  The appropriate treatment 
for this condition is CPAP or BiPAP.  There is no evidence of failure of BiPAP.  Furthermore, the enrollee has 
not been using the ventilator a sufficient amount to be effective.  The most recent usage report indicates 23.8% 
of nights with at least 4 hours of usage, which does not meet the minimum requirement of 70% of nights.  A 
home ventilator is 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home ventilator, any type, used with non-invasive interface, (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says claims 
for coverage of this service within the clinical trial should be submitted to Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials.  
 
In this case, you asked the Plan to pre-approve the requested services as part of a Medicare claims clinical trial. 
Based on the information provided, the enrollee is not enrolled in an approved clinical study for percutaneous 
image-guided lumbar decompression .Therefore, we decided that the Plan does not have to pre-approve a 
percutaneous image-guided lumbar decompression.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member could be transitioned to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for terminal brain cancer. The enrollee is not 
intubated/ventilated. The enrollee has been deemed appropriate for hospice. There is no evidence that the 
enrollee requires services that are not currently available. The enrollee can then be transferred/discharged to a 
lower level of care for any ongoing needs. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the guidelines for SNF placement. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have IV 
antibiotics, new enteral feedings or other ongoing SNF level skilled nursing need. She does not currently have 
complex wound care and does not require a SNF admission for a potential wound vac. Her functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.  She does 
not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in 
a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says you would benefit from skilled nursing facility/subacute rehab to achieve the previous level of function.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. You were admitted for treatment of a sacral decubitus ulcer. All 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 there is documentation of a need for physical and occupational therapy, the documentation does not support a 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. 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 admission to an inpatient rehabilitation facility (IRF).