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

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee. 
 
You asked the Plan to pre-approve a 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 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 mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically reasonable and necessary. This enrollee has 
COPD and severe obesity, with recurrent admissions for exacerbations of COPD. Arterial blood gas studies in 
the hospital are consistent with acute on chronic hypercarbic respiratory failure. The enrollee may benefit from 
BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve memory seating requested under code K0108, a phone 
holder requested under code K0108, two tablet holders requested under codes E1028, Omni 2 control requested 
under code K0108, and a backrest rail requested under code K0108. 
 
You asked the Plan to pre-approve the memory seating, the phone holder, the two tablet holders, the Omni 2 
control, and the backrest rail. You say that the items in dispute are medically necessary, and the Plans denial is 
inappropriate. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that Code K0108 must not be used for any component or feature of an 
expandable controller at the time of initial issue. The reimbursement for any type of complete expandable 
controller is included in the allowance for codes E2377. The rules also say that wheelchair seat and back 
cushion codes are all-inclusive and use of HCPCS code K0108 for added components is incorrect. The rules 
say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as 
equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The memory seating, the phone holder, and the tablet holders at issue in this appeal do not serve a purpose that 
is primarily medical in nature. These items are available to the general public and would be helpful even to 
those who are not sick or injured. The Omni 2 control at issue in this appeal is being requested under code 
K0108 which is not to be used for any component or feature of an expandable controller at the time of initial 
issue. In addition, the Plan has already approved coverage for code E2377, and any type of complete 
expandable controller is included in this approved code. The backrest rail at issue in this appeal is being 
requested under code K0108, which is incorrect use for added components. In addition, wheelchair seat and 
back cushion codes are all inclusive and the Plan has already approved code E2620 for a positioning back 
cushion. Therefore, we decided that the Plan does not have to pre-approve memory seating requested under 
code K0108, a phone holder requested under code K0108, two tablet holders requested under codes E1028, 
Omni 2 control requested under code K0108, and a backrest rail requested under code K0108.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS). 
 
You asked the Plan to pre-approve a VASS. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested item is experimental/investigational. 
 
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 a VASS. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that an elevated vacuum system is not proven superior to a standard socket and therefore does not meet 
Medicare medical necessity criteria. A review of the medical literature indicates that further research is needed 
with clinical trials that recruit larger sample sizes and report long-term outcome data for the requested vacuum 
suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a VASS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 7, 2022 billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 0037U provided on October 6, 
2021. 
 
You asked the Plan to pay for the genetic testing. 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 code 0037U is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on September 17, 2021. This means the billed date of service is inconsistent 
with the laboratory service collection date. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the genetic testing coded 0037U provided on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that recent data, along with the Champion 
Ide clinical study and the real-world evidence studies, support the clinical benefit of remote hemodynamic 
monitoring. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMS device has not been demonstrated in the peer-reviewed literature. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found while subsequent follow-up studies have been encouraging and suggest an 
improvement in heart failure symptoms, there have not been long-term data attesting to improved outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from May 23, 2022, to 
May 25, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the Plan underpaid this claim. The 
Plan denied your request. The Plan says it has approved the inpatient stay from May 17, 2022, to May 22, 
2022. However, the additional days from May 23, 2022, to May 25, 2022, were not medically necessary. The 
patient had no complications on these days requiring an inpatient level of care. 
 
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 inpatient hospital services. Our reviewer 
says that the inpatient hospital services provided from May 23, 2022, to May 25, 2022, are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the 67-year old enrollee received treatment for a diagnosis of a fracture of an unspecified part of neck of left femur. The request for 
approval of the hospitalization was partially approved for five days of inpatient stay from May 17, 2022, to 
May 22, 2022, and denied for 3 days of inpatient stay from May 23, 2022, to May 25, 2022, due to lack of 
medical necessity. The member was stable and waiting to be sent to rehabilitation. The documentation indicates 
that during the days in question the enrollee did not require any inpatient diagnostic studies or therapeutic 
interventions 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided from May 23, 2022, to May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on April 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 anesthesia services provided on April 8, 2022, by 
an out-of-network (OON) provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the needed physical therapy and occupational therapy can be provided 
at a lower 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. The 
complexity of the your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and shortness of 
breath after missing 2 dialysis sessions. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (93010) provided on May 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a bundled 
code. 
 
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. The Plan argues that code 93010 is a column II code to column I code 93000. 
While this is true, the Plan has not provided documentation showing that code 93000 was billed on the date of 
service in question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the services (93010) provided on May 6, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an Aurora Zip device. 
 
You asked the Plan to pre-approve placement of an Aurora Zip device. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested services are experimental/investigational. 
 
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 placement of an Aurora Zip device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Aurora Zip device is experimental. More research is needed to 
demonstrate the safety and efficacy of the device. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an Aurora Zip device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of an Aurora Zip device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service April 17, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 74176 is bundled into 
payment for code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service April 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed to the enrollee for March 16, 2021, under 
code 88305. 
 
You asked the Plan to pay this claim. The Plan denied your request. The Plan says while a portion of this claim 
was paid, code 88305 is a duplicate billing from the same provider. This code was paid on a previous claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. We looked 
at the file and Medicare rules. The file includes evidence that code 88305 was previously paid on June 21, 
2021. Based on this information, we decided that the Medicare rules for code 88305 have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services billed to the enrollee for March 16, 
2021, under code 88305.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the spine. 
 
You asked the Plan to pre-approve MRI services. You say that this imaging is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested MRI 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says that 
the requested imaging service is not medically reasonable and necessary at this time. Our physician reviewer 
found in this case, there is no record of conservative measures for neck pain or red flags for MRI services. 
More conservative measures are needed before coverage of an MRI will be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) scan of the spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (64555), and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve peripheral nerve stimulator (PNS). You say that the requested peripheral 
nerve stimulator is not being employed to assess the enrollee's suitability for permanent implants. You say that 
the enrollee needs this item to treat their chronic intractable knee pain which has continued after 2 knee 
replacements. You also say that the requested item is medically necessary. The Plan denied your request. The 
Plan says the requested PNS is not medically necessary. 
 
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 peripheral nerve stimulator (PNS). Our 
reviewer says that the requested PNS is not medically necessary. Our physician reviewer found the peripheral nerve stimulator is considered experimental/investigational for knee pain. Therefore, the reviewer found that 
the requested PNS is considered not medically reasonable or 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 peripheral nerve stimulator (PNS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array 
(64555), and implantable neurostimulator electrode (L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on June 3, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/NPP service, because they do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on June 3, 2020.