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

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface (E0466) from December 28, 2021 to March 27, 2022. 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee has chronic respiratory failure due 
to COPD. The enrollee will now require frequent duration of non-invasive ventilation. The Plan denied your 
request. The Plan says the records do not show medical necessity for the 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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a home ventilator is not medically necessary. This enrollee has COPD with mild CO2 retention when acutely will with pneumonia and sepsis. But chronic CO2 retention has not been documented with an 
ABG while awake and stable. The records do not include pulmonary function tests to support the diagnosis of 
COPD and establish severity. The enrollee is severely obese and could have obesity-hypoventilation syndrome. 
Medicare does not cover a home ventilator for that diagnosis, or when used as Bipap. Bipap has apparently not 
been tried at home and there is no documented failure of 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home ventilator, any type, used with non-invasive interface (E0466) from December 28, 
2021 to March 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is essential to 
provide the enrollee with non-invasive ventilation therapy to aid in improving his quality of life, decrease his 
fatigue and shortness of breath, and allow him more time at home with his family. You say that home bilevel 
positive airway pressure (BiPAP) is not appropriate for meeting the enrollee's ventilatory requirements. The 
Plan denied your request. The Plan says the request for the ventilator is not justified given the use of the 
ventilator in average volume-assured pressure support (AVAPS) mode, that could equally be provided by 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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home 
ventilator is not medically necessary. The enrollee has chronic obstructive pulmonary disease (COPD), with 
mild carbon dioxide (CO2) retention on an arterial blood gas (ABG) done during acute illness. But there is no 
ABG when medically stable as an outpatient. The enrollee may benefit from BiPAP at home. Certain BiPAP 
devices can provide the AVAPS mode of support at less cost to the enrollee. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are 
available in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out-of-network (OON) provider.
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 has sufficient acuity to 
require long-term management. The Plan denied your request. The Plan says the denial of authorization for 
LTACH service is correct. 
 
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 stable and improving and should only require additional short-term 
acute care services that can be safely administered at the current facility. There are not services at the LTACH 
that the enrollee requires that are not already available at the current facility. 
 
 
  
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 the acute inpatient hospital care provided from  
October 3, 2020, through October 4, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says 
enrollee does not meet the MCG Hypertension ORG criteria. 
 
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 record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two 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 from October 3, 2020, through  
October 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department (ED) evaluation provided on April 25, 2021, 
billed with code 99285-25. 
 
You asked the Plan to pay for the ED evaluation. You say that the enrollee was seen twice on this date of 
service, and both visits are payable. The Plan denied your request. The Plan says that more than one unit of 
99285 was billed for the same date of service. The first unit was paid. There is no additional documentation 
supporting an additional service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is not supported by the record. The record clearly 
shows that the physician at issue in this case evaluated and treated the enrollee prior to transferring the enrollee 
to the physician listed on the paid claim. The rules clearly indicate that if two physicians evaluate a patient in 
the ED on the same date, both are allowed to bill for this service. Though these were billed by the same group, 
the services are distinct and were provided by two different physicians. As such, the Plan's denial rationale that 
only one unit is supported is not substantiated. Therefore, we decided that the Plan has to pay for the 
emergency department (ED) evaluation provided on April 25, 2021, billed with code 99285-25.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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. The Plan denied your request. The Plan says your condition 
requires further treatment in the acute care hospital. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for a myocardial infarction and coronary artery bypass 
grafting. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 11, 2021, billed 
with codes 82607, 86141, 80061, 82306, 82728, 82746, 82784, 82785, 83036, 84165, 84403, 84439, 84481, 
86317, and 86803. 
 
You asked the Plan to pay for the lab testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says this claim was billed with an inappropriate POS code. 
 
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 lab testing 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 testing provided on March 11, 2021, billed with codes 82607, 
86141, 80061, 82306, 82728, 82746, 82784, 82785, 83036, 84165, 84403, 84439, 84481, 86317, and 86803.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 25, 2021, to 
April 28, 2021, billed with DRG 854. 
 
You asked the Plan to pay for inpatient care as billed with DRG 854. You say that these services were billed 
correctly and are supported in the medical records. The Plan denied your request. The Plan says DRG 854 is 
not supported as the primary diagnosis of sepsis, unspecified organism (A41.9) and additional diagnosis of 
acute kidney failure, unspecified (N17.9) are not supported. The Plan says that the primary diagnosis is 
calculus of gallbladder with acute cholecystitis without obstruction (K80.00) is more appropriate, and therefore 
these services should be paid at DRG 419. 
 
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. DRG 854 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 inpatient care as billed with DRG 854. Our 
reviewer says that the record does not support the services provided as billed. Our physician reviewer found 
that the enrollee presented to the facility with abdominal pain. On presentation, the enrollee was noted to be 
alert and oriented, non-toxic, and in no acute distress. The enrollee was diagnosed with cholelithiasis with acute 
cholecystitis requiring laparoscopic cholecystectomy. There was no documentation of sepsis. The review has 
determined that the medical records did not support the billing of primary diagnosis - sepsis, unspecified 
organism (A41.9) and additional diagnosis acute kidney failure, unspecified (N17.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 854 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from April 25, 2021, to April 
28, 2021, billed with DRG 854.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on August 3, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that POS code 81 is appropriate for this 
testing. The Plan denied your request. The Plan says the POS code reported does not match the location where 
the sample was taken. 
 
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 Guardant360 CDx testing 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 Guardant360 CDx testing provided on August 3, 2021.
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. The Plan denied your request. The Plan says it is not reasonable to 
expect you will be able to fully benefit from the intensity of services. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for respiratory failure and cardiac arrest after resection of 
adenocarcinoma. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 patient is medically ready to start acute rehab. 
The Plan denied your request. The Plan says the patient's condition can be managed 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. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for memory problems and gait instability and their 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse/BMP allograft Allograft (CPT code 
20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says bone Morphogenic Protein-2 (INFUSE Bone Graft, BMP, BMP2) is considered 
experimental and investigational for posterior spinal fusions because its safety and effectiveness for this 
indication has not been established. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found BMP is experimental in the posterior lumbar spine. It is only Food and Drug Administration 
(FDA) approved for anterior lumbar use. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse/BMP allograft Allograft (CPT code 20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289 and C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee needs this device and 
procedure due to their worsening heart failure. You state you have seen patients symptoms worsen and believe 
the enrollee has been on the edge of hospitalization many times. You state the totality of the evidence along 
with the clinical study and the real-world clinical studies support the benefit of monitoring. The Plan denied 
your request. The Plan says the services are not 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT code 33289 and C2624).