Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (85060) provided on August 20, 2021. 
 
You asked the Plan to pay for the blood smear. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the record. Specifically, this claim was billed with the on-
campus outpatient hospital place of service code. CPT code 85060 has a professional/technical component 
indicator of 8 meaning that payment for this service is not made for hospital outpatients. Based on this 
information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we 
decided that the Plan does not have to pay for the blood smear (85060) provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continues inpatient hospital care provided on September 
25, 2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 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 care. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the enrollee was 
hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan 
facility after the emergency room evaluation on September 3,2021. There was no documentation provided 
indicating medical necessity for post-stabilization care services at the nonPlan facility. The treating physician 
did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer 
on any dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the continues inpatient hospital care provided on September 25, 2021.
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 this device is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested equipment is not medically reasonable and necessary. Our physician reviewer found a home 
ventilator is not medically necessary. You have COPD/asthma and obstructive sleep apnea. There is no 
evidence from an arterial blood gas test that the patient has CO2 retention. Continuous positive airway pressure 
and bileval positive airway pressure have not been tried. Medicare does not cover a home ventilator when used 
as bilveal positive airway pressure device. The denial is upheld.  
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have remained medically stable and have 
done well with intermittent skilled rehab services. You do not require skilled nursing and/or skilled therapy 
services on a daily basis. You do not have any parental medication; complex wound care or nutrition given via 
a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your 
physical function is at or near her baseline. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), 
provided on October 11, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that the documentation submitted did not include a valid proof of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM and supplies have been met. Specifically, a valid proof of delivery was submitted. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on October 11, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on 
December 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
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 code 95885 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 
95909 is nerve conduction studies; 5-6 studies. The CPT Code Manual definition of code 95955 is 
electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery). 
 
We find that CPT codes are not supported in the medical record. Specifically, the description of the billed 
codes is not documented in the provided records. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the intraoperative neuromonitoring services provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records do not show that a high frequency chest wall oscillation device has 
been tried and failed. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Volara System is not medically necessary. This system combines positive end-expiratory airway 
pressure, airway flow oscillation, and nebulization. There is inadequate evidence that this system is beneficial 
in cystic fibrosis, or that it is superior to high-frequency chest wall oscillation for airway clearance. It would 
also duplicate current nebulizer therapy. 
 
 
 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Volara system for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled 
nursing services (G0299). 
 
You asked the Plan to pre-approve the HHA and skilled nursing services. The Plan denied your request. The 
Plan says there is no documented evidence of physical decline in the last 6 months, emergency room visits, or 
inpatient visits. The Plan also says that your needs could be better supported by a more appropriate service such 
as Personal Care and Homemaking or solely homemaking. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 HHA and skilled nursing services. 
Our reviewer says that home health skilled nursing services and any associated home health aide (HHA) 
services are not medically necessary or reasonable. Our physician reviewer found the enrollee is not 
homebound. Our reviewer found that the enrollee does not have documented skilled nursing needs. Our 
physician reviewer also found that custodial care can be provided by other means. 
 
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 HHA and skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled nursing 
services (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical notes do not indicate that you can use the requested group 3 power 
wheelchair safely and independently. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered if 
Medicare criteria have been met.  
 
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 requested services are not considered medically reasonable and necessary in this case. You have a mobility 
deficit that impairs participation of MRADLs in the home and are unable to be helped by a walker or cane. You 
are unable to self-propel a manual wheelchair, but the documentation does not support that caregivers are 
unable to propel an optimally configured manual wheelchair. The documentation does not support that you can 
safely maneuver the requested wheelchair. The September 8, 2021 wheelchair evaluation states "Vision: 
deficits for perception and unable to safely negotiate control of chair." In addition, it states "it is recommended 
to have options for mom to control chair from behind and power mid wheel drive chairs is needed to 
accommodate weight and allow mom to manage over uneven terrain in community." Additionally, the 
December 13, 2021 physician exam did not include video on the telemedicine visit and there is no recent 
objective exam in the physician medical progress notes that support the requested wheelchair is safe for you to 
use. The physical therapy addendum on October 14, 2021 states that the ability of the patient to maneuver the 
power chair has not been personally observed due to lack of equipment available for you to use. Our physician 
reviewer found that your condition does not meet criteria for these items. 
 
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 Group 3 power wheelchair with multiple power options and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and received IVIG. You were at a maximal assist to dependent level for functional mobility. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says your 
request for approval of a continued admission in a SNF does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continued skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve additional home health services. You say that this care is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for additional home health 
skilled nursing services have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the requested home health services are not medically reasonable and necessary. Our 
physician reviewer found the documentation does nota support that the member requires additional skilled 
nursing services to provide treatment that is medically necessary. The member does not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve the members 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. 
The member has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not 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 additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 additional home health skilled nursing visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the plan approved eight visits, but four visits remain denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the plan. The patient has had 
prior therapy and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, or that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The patient should be able to 
transition to an independent home exercise program. The requested services are not part of a maintenance 
program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional physical therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81405, 81408, 81407, 81406) provided 
December 28, 2020. 
 You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these tests were for screening purposes and are non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, cardiovascular risk assessment testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for lab services (81405, 81408, 81407, 81406) provided December 28, 2020.