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 ventilator is to be used for the treatment 
of COPD. 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 the enrollee has severe COPD and 
was recently hospitalized because of pneumonia. ABGs were consistent with acute on chronic hypercarbic 
respiratory failure. There are no ABGs done while stable to confirm chronic CO2 retention. If the enrollee does 
have chronic CO2 retention, BiPAP with AVAPS during sleep may be of benefit. Medicare does not cover a 
home ventilator when used as 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 (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from November 20, 2021, to 
November 23, 2021, at the Diagnosis Related Group (DRG) billed. 
 
You asked the Plan to pay for inpatient care at the billed DRG. You say that these services were billed 
appropriately and are supported in the medical records. The Plan denied your request. The Plan says that the 
medical records do not support the billing of sepsis, unspecified organism (A41.9) or severe sepsis without 
septic shock (R65.20). Therefore, the billed DRG is not supported. 
 
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 included the necessary medical records in the case 
file. Without this information, we cannot verify the Plan's decision. Therefore, we decided that the Plan has to 
pay for inpatient hospital care provided from November 20, 2021, to November 23, 2021, at the Diagnosis 
Related Group (DRG) billed.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient services from December 6, 2022, forward. 
 
You asked the Plan to pre-approve acute inpatient services from December 6, 2022, forward. You say that the 
services are medically necessary. The Plan denied your request. The Plan says that this is a readmission within 
30 days for the same condition so it cannot be separately paid. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 acute inpatient services from December 
6, 2022, forward. Our reviewer says that the services are medically necessary. Our physician reviewer found 
the enrollee had recently been admitted and treated for mental status changes due to hepatic failure/volume 
depletion. The enrollee is noncompliant with medical therapy. The enrollee had evidence of a urinary tract 
infection. He was treated with IV antibiotics and required admission and medical therapy. The review has 
determined that the readmission was medically necessary and was not the result from a premature discharge 
from the same hospital.  
 
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 services from December 6, 2022, forward have been met. 
Therefore, we decided that the Plan has to pre-approve acute inpatient services from December 6, 2022, 
forward.  
 
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 pay for a pneumatic compression device (E0675) provided on 
February 16, 2022, to March 11, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed item. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the provider discussed the need for this equipment or how it would be used. 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 a pneumatic compression device (E0675) 
provided on February 16, 2022, to March 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan (93880) provided on June 8, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary and was 
performed at the request of the enrollee's referring provider. The Plan denied your request. The Plan says that 
this service was not billed with an appropriate diagnosis code per Local Coverage Article A57592. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given 
by a contract provider are considered approved by the plan unless notice is provided that the services will not 
be covered. The plan follows these rules. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the article cited by the Plan for this coding denial does not apply to 
outpatient services provided in the state where the service at issue was performed. In addition, the record 
indicates that the enrollee was referred for the duplex scan by a contract provider. The file does not show that 
the plan provided notice that this scan would not be covered. Under Medicare rules, this means that the duplex 
scan is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the duplex scan 
(93880) provided on June 8, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two ophthalmology visits with an out-of-area provider. 
 
You asked the Plan to pre-approve these services. You say that you are traveling out of state for a few months 
and need treatment. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that the enrollee is leaving the Plans service area with 
a known need for treatment. The services are not for an unforeseen illness or injury or emergent condition. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve two ophthalmology visits with an out-of-area 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99202, 95910, and 95886 provided on March 9, 2022. 
 
You asked the Plan to pay for codes 99202, 95910, and 95886. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 find that CPT codes 99202, 95910, and 95886 are not supported in the medical record. Specifically, these 
codes were billed with diagnosis codes G56.01 (carpal tunnel syndrome, right upper limb) and G56.02 (carpal 
tunnel syndrome, left upper limb). There is a more appropriate bilateral code available for the correct diagnosis. 
This claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
codes 99202, 95910, and 95886 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 99202, 95910, and 95886 provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88381 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 88381. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service was not billed in accordance 
with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure code 88381 is a physician pathology service which has both a professional component 
(PC) and a technical component. This service was not billed with modifier 26 to indicate that only the 
professional component payment is requested. This means that payment is requested for both the PC and TC of 
this service. However, this service was provided to an enrollee who was in an outpatient hospital setting at the 
time the sample was collected, which means that the TC component is bundled into the facility payment. The 
TC portion of this service is not separately payable, and therefore this service is supported as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 88381 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88381 billed for date of service 
March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) image capture 
(D0383). 
 
You asked the Plan to pre-approve a cone beam CT image capture. You say that the service is necessary. The 
Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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 pre-approve a 
cone beam computed tomography (CT) image capture (D0383).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 28, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a valid proof of delivery 
was not submitted. 
 
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. The delivery ticket does not contain an order number or 
tracking number. 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 durable medical equipment 
(DME) provided on May 28, 2022.
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 you do not have strength in your legs. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for durable medical equipment (DME) miscellaneous 
(E1399), DME set-up (A9901) and sales tax (S9999) provided on June 7, 2022. 
 
You asked the Plan to reimburse you for miscellaneous DME. You say that you received a prescription for the 
requested item from your provider. You thought the insurance would cover the equipment. The Plan denied 
your request. The Plan says the service or item in question is not covered under your contract under any normal 
circumstances. The service sought or obtained by you was or will be rendered by a provider who is not under 
contract with the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for durable medical equipment 
(DME) miscellaneous (E1399), DME set-up (A9901) and sales tax (S9999) provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options is 
covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document that you 
have any pressure injuries or require intermittent catheterization of the bladder that requires the power tilt and 
recline system. You have use of the upper extremity and can operate and control a wheelchair's power options 
using the switches included in a basic wheelchair. The criteria for coverage of the Group 3 PWC with multiple 
power options are not met and the services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from March 6, 2022, to 
April 8, 2022. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says there is no 
authorization for this admission. 
 
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 inpatient care provided from March 6, 2022, to April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80503 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 80503. The Plan denied your request. The Plan says payment for 
code 80503 is bundled into payment for code 84165.  
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 80503 
is a column II code to column I code 84165. 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 80503 billed for date of service June 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelstar. 
 
You asked the Plan to pre-approve Trelstar. You say that due to being high-risk for prostate cancer, you would 
like the enrollee to be started on Trelstar for optimal management. The Plan denied your request. The Plan says 
multiple attempts were made to contact the physician, but they were not able to be reached to request the 
clinical information needed to evaluate this case. 
 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 Trelstar. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Trelstar. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that 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 Trelstar have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trelstar.