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

 
We decided that the Plan does not have to pay for SNF care provided from January 4, 2022, to  
January 21, 2022. 
 You asked the Plan to pay for SNF care. You say that the SNF care is medically necessary. The Plan denied 
your request. The Plan says the SNF care is not medically necessary. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee 
had stable vital signs. The enrollee was treated for back pain. Regarding rehabilitation services, the enrollee 
received physical therapy at a non-skilled level of 3 times per week and an occupational therapy evaluation 
only. The enrollee required a mechanical lift for transfers. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis. As a practical matter, this enrollee does 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 pay for SNF care provided from January 4, 2022, to January 21, 2022.
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 a ventilator is medically necessary because 
a BiPAP will not meet your needs. The Plan denied your request. The Plan says you have not been diagnosed 
with a disease that would support coverage of this item. The diagnosis of COPD is questioned and there was 
not supporting documentation provided. There is no evidence to suggest chronic respiratory failure. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found you are described as having 
chronic respiratory failure with hypoxia and Chronic Obstructive Pulmonary Disease (COPD), but the COPD 
diagnosis is not documented with pulmonary function tests. There is no documentation of CO2 retention on an 
arterial blood gas reading.  There are no diagnoses of neuromuscular disease or thoracic restrictive disease.   
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 pay for the nervous system function testing (95923) provided on July 
13, 2021. 
 
You asked the Plan to pay for the nervous system function testing (95923). You say that this service was 
medically necessary and was reported correctly. The Plan denied your request. The Plan says the 
documentation does not support billing code 95923. 
 
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 95923 is testing of autonomic nervous system function; 
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. 
  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 nervous system function testing (95923). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report does not include testing of autonomic nervous system function. Therefore, this 
service cannot be verified. 
 
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 nervous system function testing (95923) have not been met. Therefore, we 
decided that the Plan does not have to pay for the nervous system function testing (95923) provided on July 13, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA disc allograft. 
 
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 the enrollee has lumbar intervertebral 
disc degeneration. The requested VIA allograft is considered experimental in nature, as more research is 
needed. The services are 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 VIA disc allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venography (75822) provided on April 8, 2022. 
 
You asked the Plan to pay for venography. You say that the service should be paid as billed. The Plan denied 
your request. The Plan says the code at issue is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 75822 is a column II code to column I code 37238; however, 75822 
was billed with a modifier.  
 
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 venography. Our reviewer says that the services were not 
billed correctly. Our reviewer found in this case, the venography was performed post intervention and was not 
performed in a different anatomical site. Therefore, this procedure cannot be verified as separate independent 
procedure from CPT 37238. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venography have not been met. Therefore, we decided that the Plan does not 
have to pay for venography (75822) provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of care in a 
long-term acute care hospital. The Plan denied your request. The Plan says your medical record shows that you 
do not meet the Medicare guidelines. 
 
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 you are receiving appropriate care at the present setting. You do not require services 
at the LTACH that are not available at the acute care hospital where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need 
additional rides above the 48 one-way rides to locations other than your Primary Care Provider's office due to 
going to dialysis 3 times per week. You say that your life depends on this and you have no other way of going 
to appointments as you are in a wheelchair. The Plan denied your request. The Plan says your request for more 
transportation benefits goes beyond your benefit limit. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit only 
covers up to 48 one-way rides per year to other health care related locations (such as to the pharmacy or 
specialist appointments). Therefore, we decided that the Plan does not have to provide coverage for additional 
routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
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 the enrollee has amyotrophic lateral 
sclerosis (ALS) with excessive airway secretions and poor cough. She is using bi-level positive airway pressure 
(BiPAP) and has tried and failed a mechanical insufflation/exsufflation device. The provided records do not 
document and review of the current medical literature does not indicate that the Volara system improves 
clinically-important outcomes such as disease progression, need for invasive mechanical ventilation or 
survival. The services are 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 Volara system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted laparoscopy procedure, abdomen, peritoneum and 
omentum provided on January 10, 2022 (49329). 
 
You asked the Plan to pay for an unlisted laparoscopy procedure, abdomen, peritoneum and omentum. You say 
that the services were billed correctly. The Plan denied your request. The Plan says the documentation does not 
support the billed 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. 
 In this case, the CPT Code Manual definition of code 49329 is an unlisted laparoscopy procedure, abdomen, 
peritoneum and omentum. 
 
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 an unlisted laparoscopy procedure, abdomen, peritoneum and 
omentum. Our reviewer says that the services were not billed correctly. Our reviewer found medical 
documentation does not support the use of procedure code, after review of the documentation and with the 
codes billed there was no use for the procedure 49329, and the code description was not noted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unlisted laparoscopy procedure, abdomen, peritoneum and omentum have 
not been met. Therefore, we decided that the Plan does not have to pay for an unlisted laparoscopy procedure, 
abdomen, peritoneum and omentum provided on January 10, 2022 (49329).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve YAG laser capsulotomy (66821). 
 
You asked the Plan to pre-approve YAG laser capsulotomy. You say that the surgery is medically necessary. 
The Plan denied your request. The Plan says the services is available within the health Plan or medical group 
provider network. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve YAG 
laser capsulotomy (66821).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutritional therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that your physician spoke with 
you and referred you to a bariatric surgeon due to your intense back pain and bladder issues. You also say that 
you experience leg numbness due to weight and has a ruptured disc in your spine. You also say that the 
physician recommended nutritional counseling as the first step. The Plan denied your request. The Plan says 
the requested service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutritional therapy.
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 this is medically necessary for your 
condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in this way 
and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lunesta. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lunesta.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunofluorescence, per specimen; initial single antibody 
stain procedure (88346) and immunofluorescence, per specimen; each additional single antibody stain 
procedure (88350) provided on August 24, 2021. 
 
You asked the Plan to pay for immunofluorescence. You say that the services were billed correctly. The Plan 
denied your request. The Plan says there are more appropriate codes to report the service. 
 
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 88346 is immunofluorescence, per specimen; initial 
single antibody stain procedure and 88350 is immunofluorescence, per specimen; each additional single 
antibody stain 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 immunofluorescence. Our reviewer says that the services 
were not billed correctly. Our reviewer found laboratory report documents a circulating tumor cell analysis. In 
this case, there is a more appropriate procedure report for the service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immunofluorescence have not been met. Therefore, we decided that the Plan 
does not have to pay for immunofluorescence, per specimen; initial single antibody stain procedure (88346) 
and immunofluorescence, per specimen; each additional single antibody stain procedure (88350) provided on 
August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ActiGraft. 
 
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 the enrollee has a chronic venous 
pressure ulcer to the right lower posterior leg. The use of ActiGraft for the treatment of non-healing cutaneous 
wounds is not covered. The services are 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 ActiGraft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Colestipol. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Colestipol.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that the services of a private-duty nurse or other private-
duty attendant are not covered. 
 
We looked at the file and Medicare rules. The requested private duty nursing services are not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve private duty nursing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), anesthetic agent(s) and/or steroid; femoral nerve 
(CPT code 64447-59) provided on December 2, 2021. 
 
You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your 
request. The Plan says procedure code 64447 is included in procedure code 01230 and cannot be separately 
reimbursed. 
 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 injection. Our physician reviewer found 
the medical record show that procedure code 64447 was the same area as the anesthesia given for the procedure 
performed. There was also no documentation of post operative pain to also show medical necessity for this 
procedure to be billed separately. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for injection(s), anesthetic agent(s) and/or steroid; femoral nerve (CPT code 64447-59) provided on 
December 2, 2021.