Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee has a progressive 
neurological disorder, progressive supranuclear palsy, and skilled intervention is required to prevent declining 
function and qualifies for maintenance care. The Plan denied your request. The Plan says that the requested 
services are not reasonable and necessary. 
 
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 additional PT visits. Our reviewer says 
that 5 additional skilled therapy sessions are medically necessary based on clinical documentation. Our 
physician reviewer found the patient still requires physical assist with mobility impairments and is trialing 
different kinds of assistive devices during sessions. Our reviewer found that a past diagnosis of Parkinsons 
disease was upgraded to supranuclear palsy, which is typically a more aggressive neuro-degenerative disease 
from a mobility standpoint. Our physician reviewer also found that the patient does not appear to be safe 
enough for a stable home exercise plan with ongoing falls and loss of balance during therapy sessions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve 5 additional physical therapy (PT) visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator for the enrollee. 
 
You asked the Plan to pre-approve a Life2000 home mechanical ventilator. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator with 
settings that could be delivered by BiPAP with average volume-assured pressure support (AVAPS) for this 
member with bronchiectasis/COPD and interstitial lung disease with restriction 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 Life2000 home mechanical ventilator. 
Our reviewer says that a Life2000 home mechanical ventilator is not medically reasonable and necessary. This 
system is not a true ventilator because it is not capable of providing full ventilatory support. It has not been 
shown to be effective in the treatment of any lung disease in high-quality controlled trials. This patient has a 
history of COPD, although pulmonary function testing shows restrictive disease, not obstructive. There is mild 
CO2 retention on arterial blood gas. The patient may benefit from BiPAP support at night, with or without 
AVAPS. Medicare does not pay for a ventilator when used as BiPAP. Further, the patient has been intolerant of 
face mask therapy, so may be unlikely to tolerate BiPAP or a ventilator. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a home mechanical ventilator. 
 
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 Life2000 home mechanical ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel testing provided on June 6, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel will be useful at initial diagnosis or 
with refractory disease. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus gene panel testing provided on June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT). 
 
You asked the Plan to pre-approve HBO therapy. You say that this HBO therapy will aid in faster healing and 
prevent further complications. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the enrollee's wounds do not qualify for Wagner III grade and there is no evidence of 
good control over diabetes or best nutritional controls to promote wound healing. 
 
The Plan follows Medicare rules. Medicare rules state that hyperbaric oxygen (HBO) therapy will only be 
covered for certain indications. 
 
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 HBO therapy. Our reviewer says that 
the enrollee does not meet the Medicare criteria for HBO therapy. Our physician reviewer found the 
documentation indicates that the enrollee has non-healing wounds on the left foot that were described in past 
records as Wagner II grade and described as showing fat tissue, but having no tunneling, no sinus tracts, and no 
undermining. In the absence of visible bone of proven bone infection, this does not qualify for a Wagner III 
grade. In addition, there is no evidence of good control over the enrollee's diabetes and no evidence of best 
nutritional control to promote wound healing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve this item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that records show you do not have recent injury or surgery or objective evidence of 
instability. 
 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 this item. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Records do not document a 
recent injury to or a surgical procedure on the knee or knee instability documented by examination with 
objective description of joint laxity. Our physician reviewer found that your condition does not meet Medicare 
criteria for this item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee orthosis (L1852).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cervical fusion (22551, 22552, 22845) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the enrollee does not meet requirements for spinal surgery. 
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The enrollee is being 
treated for other spondylosis with radiculopathy, cervical region. He presented with pain in the left 
parascapular region that radiates into the left arm down to about the elbow. There is numbness in the left 
forearm along its ulnar aspect, radiating into the ring and little finger. Tipping his head towards his right 
shoulder does tend to mildly alleviate this. The exam reveals moderate pain. The motor exam reveals trace left 
deltoid weakness. Hypesthesia fitting with an ulnar distribution on the left side and positive Tinels at the left 
elbow. This increases paresthesias in the left hand. The MRI from January 21, 2022 showed C3-4 disc at 
normal height, broad bridge compressing thecal sac, asymmetric to the right but not cord, uncovertebral 
spurring and facet osteophyte, severe right and moderate to severe left sided foraminal stenosis, severe 
degenerative hypertrophy of the right facet joint; C4-5 disc at normal height, rounded osteophytic ridge 
compressing thecal sac but no cord, uncovertebral spurring and facet osteophyte, moderate to severe left-sided 
foraminal stenosis and severe degenerative hypertrophy of the left facet joint. Provided documentation 
demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of 
conservative treatment modalities have been documented. Our physician reviewer found that the enrollee's 
condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve cervical fusion (22551, 22552, 22845) for the enrollee.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that a SNF stay 
cannot be approved because the records do not show that you need more skilled therapy, more complicated 
medical care, complicated wound care, or antibiotics through your veins. 
 
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 a SNF 
admission is medically reasonable and necessary. Our physician reviewer found you have documented skilled 
nursing needs. You have a new ostomy and daily wound care needs. Our reviewer found that you have 
documented skilled therapy needs. You are functioning below your baseline. Our physician reviewer also 
found that daily skilled services are required to establish a maintenance program or to prevent deterioration of 
your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided January 6, 2022. 
 
You asked the Plan to pay for the dental consultation. You say that you were not told about this cost earlier. 
The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided January 6, 2022.   
Your complaint about feeling the Plan gave misinformation about what is covered is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services lasting 30-74 minutes (99291) provided 
on May 19, 2021. 
 
You asked the Plan to pay for critical care services. You say that you would like this claim reprocessed based 
on medical necessity of the care provided. The Plan denied your request. The Plan says the documentation does 
not support the billing of critical care services lasting between 30-74 minutes. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 represents 30-74 
minutes of critical care time. The documentation submitted indicates that only 25 minutes of critical care 
services were provided. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services 
lasting 30-74 minutes (99291) provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553). 
 
You asked the Plan to pay for the CGM supplies. You say that the items should be covered. The Plan denied 
your request. The Plan says there is not a valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Neither the packing slip date or the tracking delivery date 
match the date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient facility services provided on May 4, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient facility services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient facility services provided on May 4, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing home health care services (G0299). 
 
You asked the Plan to pre-approve skilled nursing home health care services. You say that you need more 
nursing visits. The Plan denied your request. The Plan says the clinical notes provided for your appeal does not 
show that you are confined to the home or in need of skilled nursing care. The medical records show that your 
wounds have been stable and only a local dressing and care is required. The Plan also says that the local care 
can be accomplished by non-skilled individuals and does not require the expertise of a registered nurse. 
 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 skilled nursing home health care 
services. Our reviewer says that skilled nursing home health care services are not medically reasonable and 
necessary. Our physician reviewer found there is no documentation that skilled nursing services are required to 
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that the 
records do not document any other acute or unstable medical conditions or changes in medication or treatment 
which would necessitate any further skilled nursing visits beyond what have already been approved. No 
medical notes from your treating physician are provided documenting a need for additional skilled nursing 
services. Our physician reviewer also found that the records do not document the need for intravenous 
medications, new tube feeding or ostomy care, or daily complex wound 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 skilled nursing home health care services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing home health care services (G0299).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that 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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has documented medical monitoring 
needs and will require skilled nursing services. The enrollee has documented new impairments in both mobility 
and activities of daily living and will require skilled therapy services. From a practical standpoint based on 
documented recommendations from provider and skilled therapists, the enrollee will be best served with daily 
skilled nursing and therapy services in an inpatient basis, in a skilled nursing 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.