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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary for the 
patient. The Plan denied your request. The Plan says the patient does not meet criteria for a home ventilator. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found this patient has severe chronic obstructive pulmonary disease (COPD), severe obesity, and heart failure with preserved ejection fraction 
(HFpEF). Spirometry is consistent with severe combined obstructive and restrictive lung disease, although the 
tracings are not provided to assess quality of the testing.  There is no arterial blood gases done while stable to 
document chronic CO2 retention. The appeal note mentions a neuromuscular component to the lung function 
impairment, but there is no documentation of this, and no diagnosis of chronic neuromuscular disease.  If this 
patient has chronic CO2 retention, they may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on November 17, 
2022, to November 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says this inpatient has been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the stability of the enrollee and without complexities of the case, it was not 
expected that the enrollee would require hospital services that would likely cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on November 17, 2022, to November 
18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not 
tried and failed the required drug(s), Avastin. There is no documentation provided indicating that the Plans 
required drug(s) would likely be less effective and/or likely have adverse effects 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on April 19, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says this claim does not meet criteria for the ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport service was not medically necessary. 
Our physician reviewer found the transportation via ambulance from the hospital to the enrollees living facility  
was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. 
 Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON wound care services. You say that the last time the enrollee left 
the facility for an appointment she broke her leg during the transfer. The Plan denied your request. The Plan 
says the enrollee resides in a facility that should provide routine wound care. The Plan says that if the enrollee 
requires more complex wound care, it should be obtained from an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal, including an in-network mobile wound care nurse 
practitioner that can see patients in their facilities. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve wound care to 
be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152-59 provided on October 20, 2022. 
 You asked the Plan to pay for procedure code 99152-59. You say that the medical records support the use of 
modifier 59 with code 99152. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 99152. 
 
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 99152 is a column II code to column I code 45385; however, 99152 
was billed with a modifier.  
 
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 procedure code 99152-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 99152. Our reviewer found the procedure report 
describes colonoscopy with sedation. In this case, sedation should be reported with an appropriate procedure 
code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99152-59 provided on October 20, 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 enrollee needs this device. The Plan 
denied your request. The Plan says the home ventilator 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 chronic obstructive pulmonary disease (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 device is not medically necessary. Our physician reviewer found that the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was successfully treated with bilevel positive airway pressure (BiPAP). The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure 
support (AVAPS) capability. The Plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria are not satisfied. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat therapeutic facet joint injections (64491, 64490). 
 
You asked the Plan to pre-approve the repeat therapeutic facet joint injections. You say that this service is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic intraarticular facet injections are not 
covered unless there is documentation on why Radiofrequency Ablation cannot be performed. The rules state 
that if there is an extended time, two years or more, since the last Radiofrequency Ablation and/or there is a 
question as to the source of the recurrent pain then diagnostic procedures must be repeated. 
 
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 repeat therapeutic facet joint 
injections. Our reviewer says that this service is not medically necessary. Our physician reviewer found the last 
facet joint intervention was more than two years ago. The records do not detail why Radiofrequency Ablation 
cannot be performed. Repeat diagnostic procedures are necessary before an additional set of injections can be 
considered. 
 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 repeat therapeutic facet joint injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat therapeutic facet joint injections (64491, 64490).
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 requires intensive inpatient therapies and 
has support upon discharge home. The enrollee requires close supervision for their medical issues. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided in another setting such as a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 enrollee does not have complex or intensive rehabilitation needs. The enrollee 
does not require frequent physiatry oversight. The enrollee does not have continuing acute care 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the request does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 parathyroid planar imaging. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found there is concern for a parathyroid adenoma as the calcium is high and 
the phosphorus is low; although the parathyroid hormone is not high, it is at the upper end of normal and the 
vitamin d is slightly low at 29.5 which can sometimes be the reason why the calcium is not higher, a 
parathyroid scan is reasonable to help localize a possible adenoma/nodule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have been met. Therefore, we decided that the Plan 
has to pre-approve parathyroid planar imaging (78070).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent observation care (99225) provided June 29, 
2022. 
 
You asked the Plan to pay for the emergency services. You say that please review along with the attached 
documentation to process and pay your provider accordingly. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99225. The definition of CPT code 99225 is subsequent observation care, per 
day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An 
expanded problem focused interval history; An expanded problem focused examination; Medical decision 
making of moderate complexity.  
 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 emergency services Our reviewer says 
that the documentation does not support that the criteria for observation care are met in this case. Our reviewer 
found the enrollee has a history of chronic migraines who presented to the emergency department with 
headache, nausea, and vomiting as well as experiencing episodes of absence seizure like activity. The enrollee 
was treated with Reglan, and Benadryl which helped. The enrollee was evaluated as alert, no loss of 
consciousness but peripheral vision was missing with leg weakness. At the time of admission, the enrollee was 
improving appropriately, however, neurology consultation was ordered. As the enrollee was improving on 
admission and only required consultation with neurology, it was not expected that the enrollee would require 
hospital services that would likely span 2 or more midnights for the migraine. 
 
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 emergency services have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent observation care (99225) provided June 29, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing visits in your home. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee requires help with insulin 
administration. You say that private duty nursing was not requested. You also say that the enrollee needs this 
service in order to regain health and maximum function. The Plan denied your request. The Plan says that the 
requested code is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has dementia and is not able to monitor their blood glucose level and 
administer Lantus consistently. The reviewer found that the enrollee does not have family or caregiver 
assistance to accomplish this safely. The reviewer also found that the enrollee is confined to home. Therefore, 
the continued home health skilled nursing care is 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve skilled nursing visits in your home.  
 
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
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 enrollee has a medical history including hypertension, chronic kidney disease and 
cardiac disease who was admitted to the hospital after a mechanical fall resulting in a right-sided hip fracture. 
The enrollee was treated surgically and has been treated for intermittent low blood pressure and dizziness. In 
this case, the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute 
rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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.