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

 
We decided that the Plan does not have to pre-approve a vacuum assisted suspension system (L5781). 
 
You asked the Plan to pre-approve a vacuum assisted suspension system (L5781). You say that the requested 
vacuum assisted suspension system (L5781) is medically necessary. The Plan denied your request. The Plan 
says the requested vacuum assisted suspension system (L5781) 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 vacuum assisted suspension system 
(L5781). Our reviewer says that the requested vacuum assisted suspension system (L5781) is not medically 
necessary. Our physician reviewer found the requested vacuum assisted suspension system (L5781) exceeds 
the enrollee's medical needs and is not proven superior to a standard socket therefore does not meet Medicare 
medically necessary criteria per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as 
Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. The literature 
reviewed indicates that further research is needed with clinical trials that recruit larger sample sizes and report 
long-term outcome data for the requested elevated vacuum suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vacuum assisted suspension system (L5781) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a vacuum assisted suspension system (L5781).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not 
meet 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 continued 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 at the time of admission, the enrollee required skilled rehab services 
to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of last 
covered day, the enrollee did not require any skilled nursing or rehab services on a daily basis. She was not 
expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, she did not require any skilled 
services on an inpatient basis, at a skilled level of care as of 12/4/22. She did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollee's function was at or near 
her prior level of function and she could be discharged to a lower level of care for further services. As of 
12/4/22, the enrollee required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on June 16, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
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 ambulance services (A0425, A0427) provided on June 16, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee's care can 
be met at an alternate level of care, such as assisted living facility with home health services or in a long-term 
care setting with part-time skilled services. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel (87503, 87632, 87634 and 
U0005) billed for date of service February 15, 2022. 
 
You asked the Plan to pay for procedure codes 87503, 87632, 87634 and U0005. You say that these services 
were necessary and should be paid as billed. The Plan denied your request. The Plan says this claim was not 
billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets.  
 
We looked at the file and Medicare rules. The panel in this case was unbundled and billed as individual 
components. Based on this information, we decided that Medicare rules for coverage of procedure codes 
87503, 87632, 87634 and U0005 have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel (87503, 87632, 87634 and U0005) billed for date of service February 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angiography and procedures to stent the iliac and renal 
arteries. 
 
You asked the Plan to pre-approve angiography and procedures to stent the iliac and renal arteries. You say that 
the requested angiography and procedures to stent the iliac and renal arteries are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested angiography and 
procedures to stent the iliac and renal arteries. 
 
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 angiography and procedures to stent the 
iliac and renal arteries. Our reviewer says that the enrollee does not meet criteria for the requested angiography 
and procedures to stent the iliac and renal arteries. Our physician reviewer found the record indicates that the 
enrollee has had imaging studies that demonstrate short segment renal artery stenosis bilaterally and mild 
atherosclerotic plaque in the arteries of the lower extremity. The record does not indicate that the peripheral 
vascular disease is causing obstruction. The record does not indicate that there is an inadequate response to a 
thorough medical management of symptoms related to the renal artery stenosis and for whom surgery is the 
likely alternative. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angiography and procedures to stent the iliac and renal arteries have not been 
met. Therefore, we decided that the Plan does not have to pre-approve angiography and procedures to stent the 
iliac and renal arteries.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires care in the LTACH. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have 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 the enrollee appears to be improving slowly but is still unstable at this time. The 
enrollee requires short-term additional acute care hospital services that can safely be administered at the current 
facility until more stable and appropriate for a lower level of care. Transfer to the LTACH would not be 
clinically advantageous and completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a noninvasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a noninvasive home ventilator. You say that you tried and failed on a 
BiPAP unit while staying in the hospital. Supporting documentation has been submitted to show why the 
BiPAP is ineffective. This is an urgent matter, and you need equipment as soon as possible. The Plan denied 
your request. The Plan says a noninvasive home ventilator is considered for coverage for patients who have 
trialed and failed BiPAP therapy. In the documentation submitted with this appeal, there was no documentation 
that you have had an adequate trial and failure using a BiPAP machine. As such the noninvasive home 
ventilator device cannot be established as reasonable and medically necessary at this time. 
 
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 noninvasive home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have chronic 
respiratory failure from chronic obstructive pulmonary disease. The record indicates that you were successfully 
treated with BiPAP. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine 
with AVAPS capability. The plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a noninvasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a noninvasive home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain in the left leg. He 
has not tried and failed a cane or a walker and there is no evidence of impaired mobility with mobility-related 
activities of daily living (MRADLs). The power scooter is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation. 
 
You asked the Plan to pre-approve hypoglossal nerve stimulation. You say that the requested hypoglossal nerve 
stimulation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested hypoglossal nerve stimulation. 
 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 hypoglossal nerve stimulation. Our 
reviewer says that the enrollee does not meet criteria for the requested hypoglossal nerve stimulation. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
meets all the above LCD criteria for the requested hypoglossal nerve stimulation implant system. Provided 
records document that the enrollee has a body mass index of 37.59 kg/m2 as of the most recent records 
provided from September 29, 2022, which does not meet 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 hypoglossal nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve hypoglossal nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 99291. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and can remain there until ready for discharge to a 
lower level of care such as an inpatient rehabilitation facility or even a skilled nursing facility. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear device implantation, with or without 
mastoidectomy (69930) and a cochlear device, includes all internal and external components (L8614). 
 
You asked the Plan to pre-approve a cochlear device implantation, and all internal and external components. 
You say that the enrollee suffers from asymmetric sensorial hearing loss and the enrollee would benefit from 
cochlear implantation. The Plan denied your request. The Plan says the request is not medically necessary 
because the enrollee's records show she does not have bilateral moderate to profound sensorineural hearing 
impairment. 
 
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 cochlear device implantation, 
including all internal and external components. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation that the right ear cochlear implant at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee, per Social Security Act, Section 1862 (a)(1)(A). Provided records do 
not document the enrollee has a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment 
as required by the NCD. 
 
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 cochlear device implantation, and all internal and external components have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear device implantation, 
with or without mastoidectomy (69930) and a cochlear device, includes all internal and external components 
(L8614).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne Liquid CDx testing (0295U) provided on May 31, 
2022. 
 
You asked the Plan to pay for FoundationOne Liquid CDx testing. You say that this was a medically necessary 
test which was provided for a covered indication. The Plan denied your request. The Plan says that this test is 
not covered by Medicare per the Local Coverage Determination. 
 
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. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given 
by a contract provider are considered approved by the plan unless notice is provided that the services will not 
be covered. The plan follows these rules. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied services based on a Local Coverage Determination 
which does not apply to the state where these services were performed. This test can be covered per the 
National Coverage Determination, and the Plan does not provide any other argument to indicate why these 
services should not be covered. Therefore, we decided that the Plan has to pay for FoundationOne Liquid CDx 
testing (0295U) provided on May 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.