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

 
We decided that the Plan does not have to pre-approve a Proteor Freedom Quattro microprocessor knee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no specific reason given for why this is 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested items exceed the enrollee's medical need, as it has deluxe features that are not 
medically necessary. There are 19 programmable modes including a Golf mode which do not serve a primary 
medical need. The device has features such as remote date capture and prosthetist app monitoring which also 
exceed the enrollee's medical and functional needs.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Proteor Freedom Quattro microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided September 
21, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99152). The Plan denied your request. The Plan 
says CPT code 76937 was overturned, and CPT code 99152 is not supported. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  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 moderate sedation services (99152). 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 documentation to support the presence of an independent 
trained observe to assist in monitoring the patient's level of consciousness and physiological status. In this case, 
this procedure code requires the presence of an independent trained observer, therefore this procedure cannot 
be confirmed as performed. 
 
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 moderate sedation services (99152) have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99152) provided September 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on September 22, 2021, 
by a licensed clinical/professional counselor (LCPC). 
 
You asked the Plan to pay for the LCPC services. You say that you recently lost your husband and have no 
family to help with your stress. You feel this should be covered since it was referred by your network provider. 
The Plan denied your request. The Plan says although you were referred for these services, Medicare payment 
cannot be made for the services of an LCPC. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program as LCPCs are not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to 
pay for the psychotherapy services provided on September 22, 2021, by a licensed clinical/professional 
counselor (LCPC).
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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab needs can be 
met safely at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 6, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that these were emergency services which 
cannot be denied per Texas law. The Plan denied your request. The Plan says this facility was not enrolled as a 
Medicare provider at the time these services were rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
The documentation does not support that this facility was enrolled in Medicare for the date of service at issue. 
Therefore, we decided that the Plan does not have to pay for the emergency room services provided on 
February 6, 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. You say that IRF care would allow the enrollee to recover better. 
The Plan denied your request. The Plan says IRF criteria are not met. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee is medically stable and does not need PM&R physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. At the current functional level without a prosthesis, the enrollee does not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy in an IRF. IRF admission is not medically necessary based on lack of medical 
complexity and lack of acute rehab nursing needs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering represented by code 
L5962, a flexible walking system represented by code L5981, a below the knee alignable system represented 
by code L5910, and a multi-axial rotation unit represented by code L5986. 
 
You asked the Plan to pre-approve codes L5962, L5981, L5910, and L5986. You say that the records provided 
support the need for the requested item. The Plan denied your request. The Plan says there is no documentation that supports the enrollee's activity subjects him to harsh environmental situations or that he engages in any 
extraordinary activities that would justify the need for extra protection when a flexible outer surface covering 
system. 
 
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 codes L5962, L5981, L5910, and 
L5986. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not reveal that the enrollee will be exposed to 
harsh environmental conditions or engaging in activities that require protection beyond the already approved 
L5704 x 2 covers. The L5910 exceeds the enrollee's medical need as there is no evidence in the physician 
documentation that the enrollee is unable to use the current L5910 alignable system approved in 2021. The 
documentation notes that the enrollee uses an assistive device and is expected to use an assistive device which 
is not consistent with K3 ambulation per Medicare criteria. Therefore, the K3 feet exceed the enrollee's medical 
need and are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5962, L5981, L5910, and L5986 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a protective outer surface covering represented by code 
L5962, a flexible walking system represented by code L5981, a below the knee alignable system represented 
by code L5910, and a multi-axial rotation unit represented by code L5986.
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 you need the device immediately, as you 
have chronic respiratory failure due to chronic obstructive pulmonary disease (COPD). You say that you are 
oxygen and bilevel positive airway pressure (BiPAP) dependent. You say that you qualify for the type of 
device being requested. The Plan denied your request. The Plan says a home mechanical ventilator set in 
intelligent volume-assured pressure support (iVAPS) mode that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
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. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary.  This enrollee has COPD and obstructive sleep apnea (OSA) and is currently using BiPAP 
for the OSA.  The BiPAP settings are not provided.  There is no PAP titration or usage report to indicate the 
BiPAP is being used and adequately treating the OSA.  There is no arterial blood gas (ABG) documenting 
carbon dioxide (CO2) retention while the enrollee is awake and stable. There is overnight oximetry showing 
oxygen desaturation while sleeping with BiPAP and oxygen at 3 liters per minute (LPM.) The enrollee has not 
been tried on BiPAP with average volume-assured pressure support (AVAPS.) The enrollee may benefit from a 
PAP titration sleep study, preferably with capnography, to determine the appropriate BiPAP and oxygen 
settings. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that it is felt that a home ventilator is 
necessary. The Plan denied your request. The Plan says this is not being ordered for a Medicare-covered 
indication. 
 
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 the home ventilator. Our reviewer says 
that the requested ventilator is not medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a 52-year-old woman with a history of morbid obesity, chronic 
hypoxemic respiratory failure, congestive heart failure, and diabetes. The Admission History and Physical 
dated 2/24/22 documents, "She does not have a noninvasive positive pressure ventilation machine at the house. She does not have any medications for chronic obstructive pulmonary disease (COPD)." The enrollee was 
placed on bilevel positive airway pressure (BiPAP) for chronic hypoxemic and hypercapneic respiratory 
failure. It is noted that there was no wheezing to suggest COPD exacerbation. The documentation is 
insufficient to support that the enrollee has neuromuscular diseases, thoracic restrictive diseases, and chronic 
respiratory failure consequent to chronic obstructive pulmonary 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic vacuum pump (L5781), shank foot system 
with vertical loading pylon (L5987) and axial rotation unit (L5984).  
 
You asked the Plan to pre-approve these accessories. The Plan denied your request. The Plan says Medicare 
coverage criteria for the requested accessories are not met.  
 
The Plan must follow Medicare rules. Medicare does not cover prosthetic accessories that are not medically 
necessary. 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 accessories. Our reviewer 
says that Medicare coverage criteria are not met. Our physician reviewer states that based on the medical 
records provided, there is insufficient documentation to support replacement of the current foot system.  
 
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 accessories have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the requested accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF is the best option for the 
enrollee. The Plan denied your request. The Plan says the enrollee's needs are custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 86-year-old man 
with a history of heart disease, stroke, dementia, lung disease, and diabetes, who was admitted to the hospital 
on 2/24/22 with systemic inflammatory response syndrome. As of 2/25/2022, the enrollee was confused and 
able to follow only one-step commands. By 3/10, he has suffered from failure to thrive.  
 
There are no required skilled nursing services. The enrollee may benefit from skilled therapy services but does 
not require this on a daily 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 19, 
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 provider did not bill as required by Medicare coding regulations. 
 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 imaging services provided to the enrollee on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injection services. 
 
You asked the Plan to pre-approve facet injection services. You say that the enrollee needs to have the 
requested injection services due to her pain levels. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for the requested facet injection services. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for certain clinical 
indications. 
 
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 facet injection services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found this enrollee has an L1 compression fraction.  There is no clinical indication of prior "diagnostic facet joint procedures" and no 
justification in the medical documentation on why a radiofrequency ablation (RFA) cannot be performed. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet injection services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the office POS 
code. The records do not support that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 6, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that 
services are not medically necessary. Our physician reviewer found it is not necessary to provide skilled 
therapy services on a daily basis. As a practical matter, the enrollee does not require the necessary services on 
an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.