Persius/hicric huggingface dataset:
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic 
obstructive pulmonary disease (COPD) but there are no pulmonary function tests to confirm airway obstruction 
or to assess severity. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no 
arterial blood gas (ABG) study to document chronic carbon dioxide retention. The enrollee does not meet the 
criteria for ventilatory support during sleep. The home ventilator is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that according to the Plan's Medicare policy 
guidelines, the requested device is considered medically reasonable and necessary when all criteria have been 
met. Per the enrollee's treating physician, the enrollee meets the medical necessity outlined in the criteria. The 
Plan denied your request. The Plan says unproven and not medically necessary procedures are 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 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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. The lumbosacral exam reveals positive bilateral straight leg raise. Strength is 4/5 
throughout his right leg. However, current evidence based medical guideline and peer reviewed literature do 
not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition as discussed above. FDA indications include implantation of the Superion 
device at one or two adjacent lumbar levels in enrollees with moderate spinal stenosis in whom operative 
treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal 
stenosis, many not at FDA indicated levels of moderate spinal stenosis. FDA contraindications include spinal 
instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. 
There is imaging evidence of spondylolisthesis with no discussion of spinal instability on flexion/extension 
films. There is no discussion of scoliosis of the lumbar spine with no documentation of the Cobb angle. There 
is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this 
enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous spacer at L4-
5, in this case, is 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry, interpretation; 16 or more markers (88189) 
provided on June 30, 2022. 
 
You asked the Plan to pay for flow cytometry. You say that you disagree with the denial and are requesting to 
have this claim reprocessed at the in-network level of benefit and you agree to accept the contracted fee 
schedule. The Plan denied your request. The Plan says they do not dispute whether or not the service was 
medically necessary; however, per CMS guidelines and the enrollees EOC, we are unable to make payment on 
a claim from a provider who does not accept Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for flow cytometry, interpretation; 16 or 
more markers (88189) provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. 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 there is no indication that the enrollees rehabilitation would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least three (3) visits weekly to regain or maintain her functional status. The enrollee can 
receive further 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from March 9, 2022 to March 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 a diagnosis of acute respiratory failure, unspecified. 
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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the laboratory studies and treatment plan did not reflect the 
diagnosis of acute respiratory failure with hypoxia. The documentation does not indicate that the diagnostic 
work-up and treatment ordered by the treating medical providers supported a diagnosis code J96.00 (acute 
respiratory failure, unspecified). In this case, the documentation does not consistently and completely support 
the assigned secondary diagnosis code. The decision to remove the secondary diagnosis code and adjust the 
DRG is upheld.  
 
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 acute inpatient hospital services provided to the enrollee from March 9, 2022 to March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 20, 2022, 
to March 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $325 
copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for inpatient hospital care. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day 
before you are discharged is your last inpatient day. 5 x $325 = $1,625. Therefore, results in the total cost 
sharing amount of $1,625. 
 
 You have been asked to pay a $325 copayment per day for inpatient hospital stay. This item/service falls within 
the 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 stay on March 20, 2022, to March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone debridement services (procedure codes 11044 and 
11047) provided to the enrollee on October 14, 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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 11044: 
 
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 
20 sq cm or less 
 
CPT 11047: 
 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each 
additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes, 
debridement; muscle flap and skin graft performed on right leg. In this case, the muscle flap is the primary 
procedure, in which the debridement would be considered inclusive to, as services were performed in same 
anatomical area.  Therefore, these procedures cannot be verified as  separate procedures. 
 
We looked at this coder's review, the file, and Medicare rules. 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 bone debridement services (procedure codes 11044 and 11047) provided to the enrollee on 
October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
July 12, 2022, to July 21, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you cannot afford 
this copayment, and would like it to be waived. 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 $360 
copayment per day, per day, for day 1-5 for inpatient hospital care. You were inpatient for 4 days, resulting in a 
$1,440 total copayment ($360 copay per day x 4 days = $1,440). 
 
You have been asked to pay a $1,440 copayment for an in-network inpatient stay. This item/service falls within 
the 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 an in-
network inpatient stay provided from July 12, 2022, to July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee tried the BiPAP, failed and was 
hospitalized. The enrollee needs this as soon as possible. The Plan denied your request. The Plan says the 
request for a home mechanical ventilator set in VAPS mode with Auto-EPAP (AE) that could be delivered by 
BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, although 
there are no pulmonary function tests to assess severity. The enrollee has been admitted twice with altered 
mental status and ABGs consistent with acute on chronic hypercarbic respiratory failure. The enrollee is using 
multiple medications with respiratory depressant activity. The enrollee likely has chronic hypercarbic 
respiratory failure and may benefit from BiPAP with AVAPS during sleep as an outpatient. This has not been 
tried as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 16, 2021, to October 18, 2021. 
 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should bep aid for. The Plan denied your request. The Plan says the determination to remove diagnosis code 
N17.9 remains upheld. 
 
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 a diagnosis acute kidney injury, unspecified. 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the documentation does not support that she had acute kidney injury 
noted after treatment in the Emergency Department (ED). The documentation does not indicate that the 
diagnostic work-up and treatment ordered by the treating medical providers supported a diagnosis code N17.9 
(acute kidney injury, unspecified). In this case, the documentation does not consistently and completely support 
the assigned secondary diagnosis code. The decision to remove the secondary diagnosis code and adjust the 
DRG is upheld.  
 
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 to the enrollee from October 16, 2021, to October 18, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met.the enrollee has 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of frequent 
infections and a weak immune system. She has not tried and failed the Plan's required drug, Gamunex-C. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Gammagard is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation in the 
submitted records that your fracture is less than six weeks old on recent imaging studies. The criteria for 
coverage are not met and the surgery is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) surgery.
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. The Plan denied your request. The Plan says advanced 
capabilities are available on devices such as a BiPAP. 
 
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 physician 
reviewer found that the enrollee has severe obesity, obstructive sleep apnea, COPD, coronary artery disease, 
dilated cardiomyopathy, and chronic narcotic treatment. You were hospitalized with acute hypoxic and acute 
on chronic hypercarbic respiratory failure, documented on arterial blood gas (ABG). You responded well to 
BiPAP. There is no ABG done while stable to document chronic carbon dioxide (CO2) retention, and no 
pulmonary function tests to assess severity of the COPD.   If you do have chronic CO2 retention, you may benefit from BiPAP during sleep as an outpatient. However, 
Medicare does not cover a home ventilator when used as BiPAP. Therefore, a home ventilator is not medically 
necessary in this 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.