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

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare requirements for an inpatient skilled nursing facility. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective; 
the enrollee received oral medications. The enrollee had stable vital signs. The enrollee used oxygen via nasal 
cannula. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational 
therapy (OT). The enrollee was at an independent to supervision level for functional mobility including gait to 
60m. The enrollee required varying assist with activities of daily living. There are no identifiable skilled 
nursing service needs. There are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 11. However, the records do not show that the specimen was collected in an office setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need to 
see a rehabilitation doctor 3 times per week to supervise therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute care hospital for coronary artery bypass grafting. Your medical problems 
are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You are given a diagnosis of chronic obstructive pulmonary disease (COPD), although there are no 
pulmonary function tests to confirm. You were recently hospitalized with pneumonia, and now requires 
oxygen. But there is no arterial blood gas (ABG) showing carbon dioxide (CO2) retention. There is no 
diagnosis of thoracic restrictive disease or neuromuscular 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is expected to benefit and 
improve with LTACH services. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and is 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. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the echocardiography (93308) provided on December 1, 2021. 
 
You asked the Plan to pay for the echocardiography (93308). You say that the service provided was medically 
necessary for the patient's health and wellbeing. You say that service was coded correctly, and the claim should 
be processed for payment. The Plan denied your request. The Plan says that an edit exists between 93308 and 
33017 and an appropriate modifier was not billed with this code edit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says CPT code 93308 is a column II code to column I code 33017. The 
Plan did not submit documentation supporting CPT code 33017 was billed on the same day for CPT code 
93308 to be considered inclusive. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for the echocardiography (93308) provided on December 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve additional home health nursing visits. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules 
for coverage for home health 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 nursing visits. 
Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation doesnt support that the enrollee requires additional skilled 
nursing services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, perform a maintenance program to maintain the enrollee's condition, and/or prevent 
deterioration.  The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations.  
 
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 nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 additional home health skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (01400) and femoral nerve injection (64447) 
provided on October 12, 2021. 
 
You asked the Plan to pay for the anesthesia and femoral nerve. 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 the 
correct Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 01400 and 64447 are not supported in the medical record. Specifically, this claim was 
billed with the inpatient place of service code while the record indicates that the member was an outpatient on 
the billed date of service. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia and femoral nerve have not been met. Therefore, we decided that the Plan does not have to pay for 
the anesthesia (01400) and femoral nerve injection (64447) provided on October 12, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says that the clinical 
effectiveness of Reblozyl in myelodysplastic syndrome without ring sideroblasts have not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Reblozyl. Our physician reviewer found 
that the enrollee has low-risk myelodysplastic syndrome. The requested use of Reblozyl is not FDA-approved 
for the enrollee's diagnosis. However, the use is supported by clinical research that appears in a medical 
journal. Lancet Oncology (Volume 18, Issue 10, October 1, 2017) allows approval without ringed sideroblasts 
or packed red blood cell treatment requirements. The requested use is not listed as not indicated, not supported 
or not recommended in any of the compendia. The documentation does support that the requested drug is safe 
and effective and otherwise reasonable and necessary for this 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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 22, 
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 the denied code is not supported in the medical records submitted. 
 
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 20931 is "Allograft, structural, for spine surgery only 
(List separately in addition to code for primary 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative note does not describe 
the use of a structural allograft. 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage 
Determination (LCD): Respiratory Assist Devices - L33800 for the requested portable ventilator set in average 
volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE). As stated in the LCD: "Claims for 
ventilators used to provide continuous positive airway pressure (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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on November 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS implant; transcatheter implantation of 
a wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring. 
 
You asked the Plan to pre-approve the CardioMEMS implant. The Plan denied your request. The Plan says 
based on the peer-reviewed medical literature and the information submitted by the provider for review, the 
request for outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management is 
considered investigational and 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 the CardioMEMS implant. Our 
reviewer says that the requested the CardioMEMS implant is not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of 
implantation of the wireless pulmonary artery pressure monitoring system (CardioMEMS) for management of 
CHF in this enrollee. The CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent 
follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of 
the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical 
usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time, the CardioMEMS system would not be considered medically appropriate and necessary in 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS implant; transcatheter implantation of a wireless 
pulmonary artery pressure sensor for long-term hemodynamic monitoring.