Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheterization or cannulation for sampling, monitoring 
or transfusion (separate procedure); percutaneous coded 36620 provided on June 15, 2022. 
 
You asked the Plan to pay for the catheterization or cannulation for sampling, monitoring or transfusion. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 
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 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. 
 
 We find that CPT code 36620 is not supported in the medical record. Specifically, the documentation submitted 
did not include a detailed procedure note for an arterial catheterization or cannulation for sampling, monitoring 
or transfusion (separate procedure); percutaneous, for the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the catheterization or cannulation for sampling, monitoring or 
transfusion have not been met. Therefore, we decided that the Plan does not have to pay for the catheterization 
or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous coded 36620 
provided on June 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Synvisc-One. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Synvisc-One is medically reasonable and necessary for the enrollee. 
The documentation does not support that the Synvisc-One is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is needed to improve the 
enrollee's chance of survival and improve his quality of life. The Plan denied your request. The Plan says the 
requested device does not meet the requirements for approval. Records do not show the requested device will 
not be used exclusively in bi-level PAP mode. The ventilator was ordered in a mode called volume assured 
pressure support (VAPS), and this can be achieved with bi-level devices such as a BiPAP machine. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure consequent to chronic obstructive pulmonary disease.  Provided records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on July 25, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not enrolled in hospice on the 
date of service at issue. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on July 14, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0429, A0425) provided on July 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the enrollee is highly motivated 
and may benefit from continuous physical therapy services to improve strength. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria, plateau has been reached in treatment, and has no medical 
need for a professionally supervised maintenance program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found no medical notes from the enrollees treating 
physician are provided documenting an order or need for additional skilled physical therapy 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle-foot system. 
 
You asked the Plan to pre-approve the system. You say that this is needed due to stumbling and falls. The Plan 
denied your request. The Plan says the described activity needs can be met with a mechanical foot. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document trial and failure of a K3 mechanical ankle/foot 
system to clearly show necessity of the microprocessor 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal ankle-foot system.
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 enrollee currently meets the LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee is receiving the appropriate 
inpatient acute care and is currently unstable for transfer to a LTACH. 
 
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 medical record does not indicate that the enrollee requires services that are not 
being 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are currently in hospital recovering from ER 
surgery on hematoma on right leg, currently experience extremes pain and swelling, in your leg needing skilled 
nursing. The Plan denied your request. The Plan says based on the records the enrollee does not meet criteria 
for admission to a skilled nursing facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 26, 2022, to 
November 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that an NOA was not submitted by the provider. Based 
on this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from October 
26, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided from July 19, 2022 to  
July 22, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the hospital/facility is responsible for 
obtaining the authorization, not the physician. The Plan denied your request. The Plan says that the member's 
Plan excludes coverage for this out-of-network service. 
 
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 
services at issue. 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 subsequent hospital care provided from July 19, 2022 to  
July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. You are needing the machine so you can keep breathing. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could be 
delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 86077. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
April 21, 2022. 
 
You asked the Plan to pay for the care. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 99222 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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the care. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the review indicates that CPT 99222 
was not supported in the medical records as there was no comprehensive history. 
 
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 care have not been met. Therefore, we decided that the Plan does not have to 
pay for initial hospital care (procedure code 99222) rendered on April 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 
93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99213) provided on September 28, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 99213 is office or other outpatient visits for the 
evaluation and management of an established patient. 
 
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 physician services. Our reviewer says that code 99213 is 
not supported in the records. Our reviewer found there is no documentation to support procedure code 99213 
was separate from code 11901. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99213) provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for July 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical 
package. 
 
We looked at the file and Medicare rules. Procedure code 99213-25 was related to and billed on the same day 
as procedure 36482. The -25 modifier is not supported in the documentation as a separate service. Payment for 
code 99213-25 is included in the global surgical package for 36482. Therefore, we decided that the Plan does 
not have to pay for procedure code 99213-25 billed for July 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on October 7, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that there is inadequate documentation provided to 
support the medical necessity for repeat professional visits at a frequency exceeding Medicare guidelines. 
 
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. Specifically, the Plan has not provided a valid Medicare rule to substantiate the 
denial. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided on  
October 7, 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.