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

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466) and a humidifier (E0562). 
 
You asked the Plan to pre-approve a portable ventilator and a humidifier. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 and a humidifier. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
documentation that the enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. As stated in the LCD, claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator and a humidifier have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a portable ventilator (E0466) and a humidifier (E0562).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider provided on 
October 14, 2021. 
 
You asked the Plan to pay for dental services. You say that you do not understand why you are being charged 
for this. The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary for your condition. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is not clear that the home is appropriate for a wheelchair as there are no 
objective measurements of the home indicating that your home provides adequate access between rooms, 
maneuvering space, and surfaces for use of the manual wheelchair that is requested. Without evidence that the 
manual wheelchair will provide adequate space in the home it is not clear that the requested wheelchair will 
significantly improve participation in MRADLs in the home. While you are noted to have degenerative joint 
disease of the hands, it is not clear why you would be unable to self-propel a standard wheelchair. Your motor 
exam was normal on 3/15/22. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted supplies and materials (99070) provided September 
19, 2021 to October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services 
received. The Plan denied your request. The Plan says documentation is required to adjudicate this 
claim/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. Medicare rules say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 In this case, the CPT Code Manual definition of code 99070 is unlisted supplies and materials used in non-
surgical procedures.  
 
We find that CPT code 99070 is not supported in the medical record. Specifically, a corrected and itemized 
claim with valid CPT codes is needed. Based on this information, we decided that Medicare rules for coverage 
of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for unlisted 
supplies and materials (99070) provided September 19, 2021 to October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heparin sodium injection (CPT code J1642) provided on 
October 22, 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 the service is not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code J1642 
is a column II code to column I code 96365. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the heparin sodium injection (CPT code J1642) provided on 
October 22, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are 
currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99292) provided to the enrollee from 
May 7, 2021, to May 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no payment is allowed for add-on codes without the appropriate primary procedure. 
 
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 99292 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99292) provided to the enrollee from May 7, 2021, to May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications after 05/13/2022, new tube feeding, ostomy care or daily complex wound care. 
You are walking household distances with a rolling walker with set-up assistance and is modified independent 
for transfers. Provided records do not document a significant decline in your functional status to necessitate 
further daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the home with home health care or in 
a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder triage test (CPT code 81479) provided on 
September 14, 2021. 
 
You asked the Plan to pay for the Cxbladder triage test. You say that the testing was necessary. The Plan 
denied your request. The Plan says Cxbladder triage testing (a screening test for urothelial (cells that line the 
bladder) cancer) does not meet Medicare criteria for testing and has been upheld (denied). The Plan states 
CxBladder triage testing is considered experimental/investigational as a screening test for urothelial cancer. 
The Plan states cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary 
regardless of the results of Cxbladder testing. Therefore, the request for Cxbladder triage testing does not meet 
Medicare criteria and has been upheld. 
 
 
 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 pay for the Cxbladder triage test. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the urinary biomarker tests such as CxBladder give significant false-negative results 
in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-
stage and low-grade tumors. 
 
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 Cxbladder triage test have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cxbladder triage test (CPT code 81479) provided on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT 
code 70450) provided on December 1, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 
70450) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid examination and selection provided on 
October 1, 2021. 
 
You asked the Plan to pay for the hearing aid examination and selection. You say that the provider is stretching 
the word of consultation. You say that all she did was tell you she's not participating, and you couldn't get your 
hearing aids there. The Plan denied your request. The Plan says the provider does not participate with the Plan's 
hearing aid vendor. 
 
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 hearing aid fitting and evaluations from the Plan's hearing aid vendor.  
 
 
  We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid examination and selection (92591) have not been met. Specifically, the services 
were provided by a provider that is not a Plan hearing vendor. Therefore, we decided that the Plan does not 
have to pay for the hearing aid examination and selection provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has bilateral carotid brutis 
with syncope. The Plan denied your request. The Plan says the recorder is not reasonable or necessary at this 
time. 
 
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 requested services. Our physician 
reviewer found that there is no history of an ambulatory electrocardiogram monitor having been performed to 
assess a possible arrhythmic etiology of syncope. There is insufficient documentation to support the medical 
necessity for insertion of an ILR 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 the 
services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs but does have documented skilled therapy needs. Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. At this point, the enrollees care 
needs are custodial and, as a practical matter, can 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for LTACH 
care have not been met. The Plan says that the enrollee's needs can be met in the current hospital setting. 
 
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 facility. 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 facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, 4 bar 
linkage or multiaxial, fluid swing and stance phase control (K1014), an addition, endoskeletal system, above 
knee or hip disarticulation, knee extension assist (L5850), all lower extremity prosthesis, shank foot system 
with vertical loading pylon (L5987) and all endoskeletal lower extremity prosthesis, axial rotation unit, with or 
without adjustability (L5984). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot/knee and ankle rotation. You say that 
the requested items are medically necessary. The Plan denied your request. The Plan says the requested items 
do not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a prosthetic leg with an advanced 
foot/knee and ankle rotation. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found medical records do not support that you 
are a K3 level ambulator to meet criteria for the requested equipment. You currently use a wheelchair for 
mobility and live in an assisted living/group home. Although records from the device vendor argue medical 
necessity of the requested device, no records from your actual treating provider clarify that you are a K3 level 
ambulator and why the requested device is the most appropriate treatment for your condition. 
 
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 prosthetic leg with an advanced foot/knee and ankle rotation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin 
system, 4 bar linkage or multiaxial, fluid swing and stance phase control (K1014), an addition, endoskeletal 
system, above knee or hip disarticulation, knee extension assist (L5850), all lower extremity prosthesis, shank 
foot system with vertical loading pylon (L5987) and all endoskeletal lower extremity prosthesis, axial rotation 
unit, with or without adjustability (L5984).