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

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 the home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This patient has severe chronic obstructive 
pulmonary disease (COPD). An arterial blood gas (ABG) done in the hospital, apparently while acutely ill, 
showed a PaCO2 of 58.9. The patient may benefit from bilevel positive airway pressure (BiPAP) during sleep, 
which can provide the average volume-assured pressure support (AVAPS) mode if necessary. But Medicare 
does not cover a home ventilator when used as BiPAP. There is no evidence of BiPAP failure as an outpatient. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM) sensor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on August 18, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT A0425 has an MUE value of 250 units, and 344 units were billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 344 units of CPT code A0425 are not supported in the medical record. The medical record only 
supports 250 units of CPT code A0425. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services provided to the enrollee on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided November 
3, 2021. 
 
You asked the Plan to pay for the laboratory test. You say that you request reconsideration of the original 
determination and cover the GeneSight psychotropic test as medically necessary. The Plan denied your request. 
The Plan says GeneSight psychotropic has not been shown to be useful and is not considered medically 
necessary and appropriate as it is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory test have not been met. Therefore, we decided that the Plan does not have to pay for 
the GeneSight Psychotropic test (81479) provided November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 14, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab tests 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 laboratory testing provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trilogy home ventilator (E0466). 
 
You asked the Plan to pre-approve a Trilogy home ventilator. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the request for a Trilogy home mechanical ventilator that would 
be set in AVAPS mode with or without Auto-EPAP (AE) and 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 Trilogy home ventilator. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity 
and likely obesity hypoventilation syndrome, made worse by chronic narcotics for pain. The enrollee also has 
severe restrictive disease on pulmonary function testing, of unclear cause. There is no data to support the 
diagnosis of COPD. The enrollee does not have thoracic restrictive disease or neuromuscular disease. The 
enrollee may benefit from bipap during sleep, which can provide the AVAPS mode if needed. Medicare does 
not cover a home ventilator when used as bipap, and the enrollee does not have a diagnosis for which a 
ventilator is covered. 
 
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 Trilogy home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Trilogy home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment program provided on March 23, 2021. 
 
You asked the Plan to pay for opioid treatment program provided. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or facility. 
 
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 
service 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 opioid treatment program provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine endovenous laser vein surgery and foam 
sclerotherapy service. 
 
You asked the Plan to pay for he routine endovenous laser vein surgery and foam sclerotherapy service. You 
say that the service was medically necessary. The Plan denied your request. The Plan says this service was not 
emergent. 
 
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 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 he routine endovenous laser vein surgery 
and foam sclerotherapy service. Our reviewer says that  Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of he routine endovenous laser vein surgery and foam sclerotherapy service have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine endovenous laser vein 
surgery and foam sclerotherapy service.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 70450 
is a column II code to column I code 70496. 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 the services (70450) provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was totally independent and functioning 
at home prior to her stroke. The enrollee's spouse is also a stroke victim and cannot drive the enrollee to any 
outpatient therapies. She needs 24-hour care and her spouse is not physically capable of managing her PEG 
feeding on the pump.  
  The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care and can 
be treated at a lower level of care such as with home health, caregiver or long-term care or under the 
supervision of a skilled therapist. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee has stabilized medically and 
is ready for discharge from the hospital. She does not require skilled nursing and/or skilled therapy services 
daily.  She is medically stable and can receive further rehab services at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary stress testing (94618) and respiratory therapy 
services (G0239) provided on October 7, 2021, through October 28, 2021. 
 
You asked the Plan to pay for the pulmonary stress testing and respiratory therapy services. You say that you 
would like reconsideration because this claim was billed correctly. The Plan denied your request. The Plan says 
this claim was not billed with an appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pulmonary stress testing and respiratory therapy services have not been met. Specifically, 
diagnosis code Z86.16 has a code first note meaning that the underlying condition must be sequenced first. Therefore, we decided that the Plan does not have to pay for the pulmonary stress testing (94618) and 
respiratory therapy services (G0239) provided on October 7, 2021, through October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the visual field examination (92083) and 
computerized ophthalmic diagnostic imaging (92133) provided on January 19, 2022. 
 
You asked the Plan to waive the copayments for the medical vision services. You say that this was preventative 
care and should be covered in full. The Plan denied your request. The Plan says these services are covered, and 
your copayments were assessed in accordance with your contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85 
copayment for each diagnostic procedure or test and a $40 copayment for each Medicare-covered exam to treat 
an eye condition.  
 You have been asked to pay a $31.41 copayment for the computerized ophthalmic diagnostic imaging, which 
falls within the diagnostic procedure or test benefit category. You have been asked to pay a $40 copayment for 
the visual field exam, which falls within the Medicare-covered exams to treat an eye condition benefit 
category. You say that these services were provided as a glaucoma screening and therefore you should not be 
responsible for any portion of the cost. However, these services were not billed as a glaucoma screening, and 
the claim shows that these services were billed with a diagnosis of glaucoma rather than a screening diagnosis.   
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the visual field examination (92083) and computerized 
ophthalmic diagnostic imaging (92133) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services (V2025, V2781, 92014) provided on 
November 19, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for routine vision care. You say that you were told by the provider that you could get 
a refund for these services. The Plan denied your request. The Plan says your benefit does not cover out-of-
network services. The provider in this case is not part of the Plan's network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only when they are received through the Plan's vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified vendor 
network. Based on this information, we decided that the Plan's rules for coverage of routine vision care have 
not been met. Therefore, we decided that the Plan does not have to pay for the vision services (V2025, V2781, 
92014) provided on November 19, 2021, by an out-of-network 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 for the enrollee. 
 
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 enrollee's ongoing skilled therapy and nursing needs 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 patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of 
obesity, immobilization syndrome, lymphedema, muscle weakness and chronic pain and is living at home with 
debility and stage 2 wounds despite home health services. The enrollees medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving with current treatment and should only require short-term additional 
acute care services that can safely be administered at the current facility until appropriate for a lower level of 
care. The patient does not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.