Persius/hicric huggingface dataset:
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 the member needs IRF services in order to return 
home independent because they live alone. The Plan denied your request. The Plan says the request 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 the member is an 81-year-old female with a medical history including hypertension, cardiac disease and Crohn's disease who was admitted to the hospital with abdominal pain with nausea and 
vomiting. She was diagnosed and treated for acute kidney injury and enteritis with a possible Crohn's disease 
flare. She was treated medically and stabilized. The most recent therapy notes indicate that the member is able 
to ambulate up to 40 feet with a walker and contact guard assistance. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 5, 
2022 to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services are medically necessary and 
should be paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 5, 2022 to December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary for 
the patient and is covered. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary because a bilevel positive airway pressure (BiPAP) device would meet the patient's needs. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease.  
The records document that the home ventilator is being requested for use in average volume assured pressure 
support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. The provided records do not clearly document trial and failure of a BiPAP device with AVAPS 
and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to 
provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 IRF services are medically necessary for the enrollee 
to be able to live independently. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
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 per the records it is obvious intensive therapy is not tolerated and imposing it on the enrollee would be cruel. Admission to an IRF is not reasonable and not consistent with Medicare rules. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat in-lab sleep study (95810 x 2). 
 
You asked the Plan to pre-approve the sleep study. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says when screening for sleep apnea, a home study is the preferred 
initial screening test or verification. 
 
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 the sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an attended polysomnography (PSG) would only be necessary if the enrollee were in significant 
heart failure or had severe chronic obstructive pulmonary disease (COPD), which does not appear to be the 
case. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat in-lab sleep study (95810 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee is needing the ventilator in order to 
regain maximum function and health. The enrollee still has respiratory issues. The Plan denied your request. 
The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-EPAP (expiratory 
positive airway pressure) 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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Provided records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. The home ventilator is being requested for use in intelligent volume 
assured pressure support (iVAPS) mode with auto-titration (AE) which could be provided by a bilevel positive 
airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this policy will be 
denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary. 
The Plan denied your request. The Plan says a home ventilator is not medically necessary because the patient 
has not tried and failed with a bilevel positive airway pressure (BiPAP) device. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of thoracic restrictive disease. The records document that the home ventilator is 
being requested for use with very low set tidal volumes (150 to 200 mL) which could be provided by a BiPAP 
device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 have multiple fractured ribs and endurance 
issues. The Plan denied your request. The Plan says the request 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 the member is an 81-year-old male with a medical history including hypertension 
who was admitted to the hospital after a fall from a ladder resulted in a vertebral fracture. He required treatment with fusion of T6-T9. He has stabilized medically. The most recent therapy notes indicate that the 
member is able to ambulate up to 1200 feet with a walker. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status.  
 
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 pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you need this wheelchair for dialysis 
appointments. The Plan denied your request. The Plan says the medical group approved a heavy-duty 
wheelchair based on the physician progress notes without a home evaluation. There is no mention that you 
need a wheelchair for mobility related activities of daily living in the home, but only for your daughter to help 
with dialysis and doctor visits. You do not meet criteria for a lightweight wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 lightweight wheelchair. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation indicates a 
mobility limitation, but it is not clear that you are unable to perform MRADLs in the home. The documentation 
indicates that you can use a walker with some shortness of breath. The documentation is not clear that your 
home is suitable for the requested wheelchair and that it will significantly improve MRADLs. The 
documentation indicates that a Periscope evaluation is pending to assess the request for the lightweight 
wheelchair need. You may use a medical wheelchair at dialysis with staff assist until the Periscope evaluation 
is complete to address the appropriateness of the requested wheelchair. There is no objective evaluation 
indicating that you propel in a lightweight wheelchair or are unable to self-propel in a standard wheelchair. 
LCD L33788 criteria have not been met for the requested wheelchair. 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 lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implantation of a wireless pulmonary 
artery pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve the transcatheter implantation of a wireless pulmonary artery pressure 
sensor (CardioMEMS). You say that the transcatheter implantation of a wireless pulmonary artery pressure 
sensor (CardioMEMS) is medically necessary. The Plan denied your request. The Plan says the requested 
transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS) is experimental or 
investigational and 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 the transcatheter implantation of a 
wireless pulmonary artery pressure sensor( CardioMEMS). Our reviewer says that the requested transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS) is not considered medically 
reasonable and necessary. Our physician reviewer found that the CardioMEMS device was approved by the 
Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to 
allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure 
(CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and 
decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient 
population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies 
remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In 
addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical 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 the transcatheter implantation of a wireless pulmonary artery pressure sensor 
(CardioMEMS) have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
13, 2022, through November 11, 2022. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was not medically necessary based on SNF 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualified for SNF coverage after October 12, 2022. The 
enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy 
needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs, custodial and intermittent, could, as a practical matter, be 
provided 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 pay for skilled nursing facility (SNF) care provided from October 13, 2022, through November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392) and 
miscellaneous Durable medical equipment (E1399). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the current portable oxygen equipment 
is too heavy for the enrollee, and it is hard to carry around safely without the enrollee hurting themself. The 
Plan denied your request. The Plan says the clinical information obtained does not indicate that the enrollee's 
current oxygen needs are not being met with the current oxygen system or they are in disrepair. 
 
The Plan must follow Medicare rules. 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 file shows that the enrollee has portable oxygen concentrator (M6 tanks). The enrollee received their 
current oxygen equipment on July 7, 2019 and is not eligible to receive new oxygen equipment until July 7, 
2024. The portable oxygen concentrator (M6 tanks) serves the same purpose as the oxygen equipment. 
Therefore, we decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392) and 
miscellaneous Durable medical equipment (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
26, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 procedure code 70450 billed for date of service November 26, 
2022.