Persius/hicric huggingface dataset:
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 requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the record indicates that the enrollee was successfully treated with BiPAP with adjusted BiPAP settings in 
the hospital. However, 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 would be available upon request. 
 
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: 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 attached are new chart notes and blood 
gases for the enrollee. The enrollee's original request for a ventilator was denied and she was discharged home. 
Now the enrollee is back in the hospital as a readmission and once again she was placed on Bipap with a 
backup rate which has failed again. Despite the use of Bipap with rate, the enrollee remains chronic 
hypercapnic. You also say the device should be approved so you can assist her staying out of the hospital and 
improve her overall well-being and not readmit again. The Plan denied your request. The Plan says the request 
for a home mechanical ventilator set in iVAPS 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 the enrollee has a diagnosis of 
respiratory failure with chronic obstructive pulmonary disease and obesity hypoventilation syndrome. Provided 
records document that the home ventilator is being requested for use in intelligent volume assured pressure 
support (IVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average 
volume assured pressure support (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: 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 you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS/iVAPS 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 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 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 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that an inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the planned procedure is not listed on the 
CMS inpatient only list. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission is 
met in this case. Our physician reviewer found the enrollee has a diagnosis of osteoarthritis of left shoulder. 
The health plan has approved the elective procedures elective left shoulder arthroplasty, possible 
hemiarthroplasty represented by CPT codes 23472 and 23470. There is no need to prospectively approve the 
inpatient admission. The enrollee is medically stable and has been provided medical clearance to undergo this 
elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span 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 an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 sensor. 
 You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the Freestyle Libre kit 
system is a continuation of therapy. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor (CGM). 
Our physician reviewer found although the enrollee has low blood glucose sugar (BGS) into the 50s and likely 
would benefit from use of the CGM; however, we are not given enough data to prove that the enrollee meets 
the Medicare criteria for coverage of the CGM. 
 
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 continuous glucose monitor (CGM) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre 14 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive rehabilitation to return 
to their prior level of functioning. You say that an IRF is the best chance for the enrollee to make a full 
recovery. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee's needs can be met at an alternate level of care. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service December 8, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service December 8, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 10, 2022. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Neither your organization nor the ordering provider in this case is a network provider with the Plan. Therefore, we decided that the Plan does not have to pay for lab services provided on June 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transperineal placement of biodegradable material, 
peri-prostatic, single or multiple injection(s), including image guidance, when performed (55874). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has unfavorable intermediate risk of 
prostate cancer. The Plan denied your request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The 
records do not show date of diagnosis, pathology report, comorbidities and full treatment plan. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transperineal placement of biodegradable material, peri-prostatic, single or multiple 
injection(s), including image guidance, when performed (55874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99225 x4 provided from May 5, 2022, to 
May 8, 2022. 
 
You asked the Plan to pay for procedure code 99225 x4. You say that the medical records support the billing of 
code 99225 provided on May 5, 2022, May 6, 2022, May 7, 2022, and May 8, 2022. The Plan denied your 
request. The Plan says the medical records do not support the billing of code 99225 provided on May 5, 2022, 
May 6, 2022, May 7, 2022, and May 8, 2022. 
 
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 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. 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 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 procedure code 99225 x4. Our reviewer says that the medical 
records do not support the billing of code 99225 provided on May 5, 2022, May 6, 2022, May 7, 2022, and 
May 8, 2022. Our reviewer found procedure code 99225 can be used for subsequent observation care, per day, 
for the evaluation and management of a patient. The code can be used if the evaluation and management of a 
patient requires at least 2 of these 3 key components: an expanded problem focused interval history, an 
expanded problem focused interval examination, medical decision making of moderate complexity. In this 
case, the documentation does not support procedure code 99225. The member was medically stable and was 
awaiting placement in a geriatric psychiatry unit or hospital. There were no active medical problems. 
 
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 99225 x4 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99225 x4 provided from May 5, 2022, to May 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthesis for your left leg (CROW boot) (L5050, 
L5618, L5634, L5654, L5673, L5910, L5940, L5981, L8400 and L8420). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the requested item is miscoded. The Plan states a complete prosthesis with K3 foot 
is not reasonable and necessary for this 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 items. Our physician reviewer 
found the provider is requesting a CROW boot not a prosthesis. Additionally, the documentation does not 
support that the enrollee is a K3 ambulator given the enrollee's need for a walker. The prosthesis for the left leg 
(CROW boot) (L5050, L5618, L5634, L5654, L5673, L5910, L5940, L5981, L8400 and L8420) exceeds the 
enrollee's medical need and are 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the prosthesis for your left leg (CROW boot) (L5050, L5618, L5634, L5654, L5673, L5910, 
L5940, L5981, L8400 and L8420).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on June 2,  2022. 
 
You asked the Plan to pay for the ambulance service. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says the ambulance transport was not 
medically necessary. 
 
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. Our reviewer says 
that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via 
ambulance from the hospital to the enrollee's residence was not medically necessary. The enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance (i.e., intravenous,  
ventilator) 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 have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport provided on June 
2,  2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral 
radiographic image (D0230), and panoramic radiographic image (D0330) provided on November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should have been covered. 
The Plan denied your request. The Plan says the enrollees benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollees benefit for the comprehensive oral evaluation and the panoramic radiographic image was 
exhausted on the date of service of April 21, 2022, and the intraoral radiographic image was exhausted on the 
date of service of November 15, 2022. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), intraoral radiographic image (D0230), and panoramic radiographic 
image (D0330) provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Avise CTD test (0312U) provided June 9, 2022 
 
You asked the Plan to pay for the laboratory service. You say that based on the enrollee's specific clinical 
diagnosis, the enrollee's physician ordered the Avise CTD test. The Plan denied your request. The Plan says the 
service does not meet Medicare coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was diagnosed with "other specified disorders involving the immune 
mechanism." Proprietary Laboratory Analyses, Avise CTD test, a combination of serological markers designed 
to improve the sensitivity and specificity of testing methods to rule in/out systemic lupus erythematosus (SLE). 
However, this test does not currently have high quality evidence to support its use leads to improved major 
outcomes such as morbidity or mortality compared to standard testing, separately ordered markers. Therefore, 
this request for Avise CTD testing will be considered not medically necessary at this time. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Avise CTD test (0312U) provided June 9, 2022