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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
 
 
 
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary ciliary dyskinesia panel (81479). 
 
You asked the Plan to pre-approve laboratory testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this test is not reasonable and necessary as it has not met the MolDx 
technical assessment review to determine that this test meets Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier.  
 
We looked at the file and Medicare rules. The requested test is not shown in the DEX database as evaluated and 
covered. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a primary ciliary dyskinesia panel 
(81479).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study (CPT code 95806). 
 
You asked the Plan to pre-approve the sleep study. You say that the service is necessary. The Plan denied your 
request. The Plan says the request does not meet the Medicare or Health Plan coverage 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 the sleep study. Our physician reviewer 
found the enrollee has not had a comprehensive sleep evaluation and there's no record that the enrollee has a 
high pretest probability of moderate to severe obstructive sleep apnea. The review has determined that the 
medical records provided do not meet the requirements listed in the NCD/LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sleep study (CPT code 95806).
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 a home 
ventilator is not medically necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) 
with frequent exacerbations and was hospitalized in July. Arterial blood gases (ABG) while acutely ill showed 
mild CO2 retention.  There is no documentation of chronic CO2 retention with an ABG done as an outpatient while stable. If the enrollee does have chronic CO2 retention, he may benefit from BiPAP with AVAPS during 
sleep 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve a repeat PSG. You say that you would like this study to be reconsidered for 
authorization to properly evaluate and assess the enrollee's obstructive sleep apnea (OSA). The Plan denied 
your request. The Plan says a facility-based sleep study is not needed since the enrollee's OSA was confirmed 
in the past. The Plan also says a new diagnostic test is not required to obtain a new positive airway pressure 
(PAP) device. 
 
The Plan follows Medicare rules. Medicare rules say that a Repeat PSG or PSG with CPAP titration may be 
indicated in circumstances listed in the Medicare rules section of this letter.  
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 repeat PSG. Our reviewer says that a 
repeat PSG is not medically necessary. Our physician reviewer found the enrollee was diagnosed with OSA on 
a PSG in 2004, and has used CPAP successfully over the years. Now the device needs to be replaced.  Our 
reviewer found that the enrollee has lost weight since the sleep study, but only 8% (189 to 173 pounds), and 
there are no other medical changes that would be expected to impact the OSA. Our physician reviewer also 
found that it is reasonable to replace the CPAP and re-initiate treatment at the same 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 a repeat PSG have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat polysomnography (PSG) (95811).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223), and subsequent hospital care 
(99232) provided from May 12, 2022, to May 13, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was no longer enrolled in hospice on 
the dates of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 11, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care 
(99223), and subsequent hospital care (99232) provided from May 12, 2022, to May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 11, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was denied incorrectly and is 
supported in the medical records provided. The Plan denied your request. The Plan says procedure code 99053 
is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and injection provided on January 11, 2022, by 
an OON provider. 
 
You asked the Plan to pay for an office visit and injection. You say that you are appealing the denial of the 
copayment. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 and injection provided on January 
11, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5298) purchased on February 1, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like to be compensated for the cost of 
the hearing aid because it was a necessity. The Plan denied your request. The Plan says these hearing aids were 
provided by a non-contracted provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aid (V5298) purchased on February 1, 2022, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that this therapy is medically necessary. The Plan 
denied your request. The Plan says additional physical therapy is not medically necessary. 
 
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 therapy 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 that you may continue to improve your lower extremity strength, but 
this does not require the services of a skilled physical therapist at this point, and you can continue with a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically reasonable 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. 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
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 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 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. Our physician reviewer 
found the enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. All medically necessary care is being provided in the current acute care 
setting. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the health plan. The health plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not 
considered medically reasonable and necessary in this case. 
 
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 he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of 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 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 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 a home 
ventilator is not medically necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD), 
severe obesity, and obstructive sleep apnea (OSA). Arterial blood gases (ABG) while acutely ill was consistent 
with acute-on-chronic hypercarbic respiratory failure, but there is no ABG done as an outpatient while stable to confirm chronic CO2 retention. Split-night polysomnography (PSG) confirmed OSA, but titration with CPAP 
and with BiPAP did not resolve the sleep-disordered breathing. BiPAP with AVAPS has not been tried. This 
enrollee may benefit from BiPAP with AVAPS during sleep. A full-night titration sleep study may be 
beneficial in determining optimal settings. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment (E0431, E1390) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the oxygen equipment. You say that these items are medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve oxygen 
equipment (E0431, E1390) to be provided by an out-of-network (OON) provider.