Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee is currently undergoing treatment at an ACH for acute-on-chronic 
respiratory failure. The enrollee has tracheotomy and feeding rube at baseline. The enrollee is not on a 
ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs 
and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to 
the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor (CGM) supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 5, 2022, to 
March 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for these 
services. 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 pay for the home health services rendered on 
February 5, 2022, to March 6, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee was admitted for COVID pneumonia and was transferred to skilled 
nursing on 9/25/22. Medical problems are stable. There are no complex nursing or rehabilitation needs. The 
enrollee does 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says inpatient admission was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the available medical records describe the enrollee as stable following the 
procedure without complications noted. The enrollee was tolerating diet and pain was controlled. The enrollee 
discharged home less than 24 hours after surgery in a stable condition. The enrollee was not expected to require 
hospital services that would likely have crossed 2 midnights. 
 
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 hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high intensity-focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve HIFU. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 HIFU. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found HIFU is not medically reasonable and necessary in this case. The records in this case are 
insufficient to confirm that you have localized prostate cancer appropriate for HIFU treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have not been met. Therefore, we decided that the Plan does not have to 
pre-approve high intensity-focused ultrasound (HIFU).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on July 
13, 2022, to July 15, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are on a limited 
income, and you cannot afford this. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 a $275 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital 
care/inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-2 for inpatient hospital services. The total 
amount you are being asked to pay is $550 ($275 x 2 days = $550). This item/service falls within the inpatient 
hospital care/inpatient hospital care benefit category. 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 copayment for 
inpatient hospital services provided on July 13, 2022, to July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided from July 21, 2022, to July 31, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 an office visit provided from July 21, 2022, to July 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients that meet certain criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) device, 
four or more leads, for multiple nerve stimulation (E0730) provided June 3, 2022. 
 
You asked the Plan to pay for the TENS device. You say that please review the claim denial for accuracy. 
E0730 is an accepted procedure code according to the Plan's Durable Medical Equipment Reference List (NCD 
280.1). The Plan denied your request. The Plan says evidence of misrepresentation. 
 
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 physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted did 
not include a valid Proof of Delivery or a delivery ticket. The submitted packing slip and proof of delivery 
belongs to date of service March 3, 2022. 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 
transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation 
(E0730) provided June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761) provided July 9, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the doctor ordered, by prescription, the elbow orthosis 
and the included are the applicable office visit notes to show compliance with the policy guidelines regarding 
reimbursement for DME. The Plan denied your request. The Plan says evidence of misrepresented services. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Based on the medical records provided there is no documentation that the elbow orthosis 
(L3761) with date of service of 07/09/2022 at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the patient. Provided records do not document any medical issues with the 
patient's elbow in this case. The only clinical note is from 02/09/2022 and this involves issues of back, leg and 
groin pain. A prescription for the elbow orthosis is provided, but as stated in the Local Coverage Article: 
Standard Documentation Requirements for All Claims Submitted to DME MACs - A55426: "Supplier-
produced records, even if signed by the treating practitioner, and attestation letters (e.g. letters of medical 
necessity) are deemed not to be part of a medical record for Medicare payment purposes. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the elbow orthosis (L3761) provided July 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 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 83789 
is a column II code to column I code G0480. 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 83789 billed for date of service June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the member must receive care from a network provider or it will not be 
covered except for urgent/emergency care, approval to see an out-of-network doctor, or kidney dialysis 
services from a Medicare-certified dialysis facility outside the Plans service area. In this case, prior 
authorization was not obtained. 
 
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 an office visit provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 24, 2021, to 
April 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue have been billed correctly for payment. The Plan denied your request. The Plan says the DRG 
originally billed is inappropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes J96.21, defined as Acute 
and chronic respiratory failure with hypoxia, and J96.22, defined as Acute and chronic respiratory failure with 
hypercapnia. 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 at the 
DRG originally billed. Our reviewer says that the inpatient hospital services at issue do not meet criteria for 
payment at the DRG originally billed. Our physician reviewer found that in this case there is no clinical or 
laboratory evidence of acute and chronic respiratory failure with hypoxia or hypercapnia. The available 
medical records do not support DRG 286 and secondary diagnosis codes J96.21 and J96.22.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 24, 2021, to April 7, 2021, at the DRG originally billed.
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 the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found this 
enrollee has diagnoses of post-polio syndrome, HFpEF with pleural effusions, coronary artery disease (CAD), 
and chronic pain on narcotics. This enrollee presented to the hospital with weakness and altered mental status. 
Arterial blood gas (ABG) test showed a normal pH and mild CO2 retention. There was mild elevation of the hemidiaphragm, confirmed to be weak on a sniff test. The enrollee is on chronic narcotics for pain, and this is 
likely playing a role in mild chronic CO2 retention, along with the weak hemidiaphragm. The mild elevation of 
the PaCO2 is not likely to be the cause of the altered mental status; more likely the decreased level of 
consciousness was contributing to the CO2 retention. There are no pulmonary function tests showing severe 
reduction in the forced vital capacity (FVC). There is no diagnosis of chronic obstructive pulmonary disease 
(COPD), thoracic restrictive disease, or specific neuromuscular diseases for which Medicare covers a home 
ventilator. There is no documentation of chronic CO2 retention with ABG done while stable. If the enrollee 
does have chronic CO2 retention, he may benefit from BiPAP during sleep. This has not been tried and failed 
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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.