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

 
We decided that the Plan does not have to pre-approve a semi-electric Hospital Bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric Hospital Bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric Hospital Bed. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found your condition does not 
require position of the body in ways not feasible in an ordinary bed or frequent changes in body position. 
Additionally, your condition does not require special attachments that cannot be fixed and used on an ordinary 
bed. 
 
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 semi-electric Hospital Bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric Hospital Bed (E0260).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services (SNF). 
 
You asked the Plan to pre-approve SNF. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the record shows that you do not meet Medicare guidelines for services in a 
skilled nursing facility (SNF). 
 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. Our reviewer says that this does 
not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve skilled nursing facility services (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 additional PT visits. You say that it is not your fault that the provider did 
not send proper medical records. You say that you have chronic back pain due to swelling at C6 and C7. You 
also say that your pain has gotten worse since you have not been able to get treatment. The Plan denied your 
request. The Plan says functional progress was not made during the initial therapy. The Plan also says that the 
additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 6 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the provided documentation does not indicate that you have 
had prior therapy and the documentation does not reveal that you require the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. The reviewer found that the documentation 
does not reveal the outcome of the initial 12 approved therapy sessions or that you require ongoing formal 
therapy. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the 
requested visits 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 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from August 1, 2021, to August 5, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that the principal diagnosis 
code, A41.9, is supported. The Plan denied your request. The Plan says the principal diagnosis code A41.9, 
Sepsis, unspecified organism, is not supported by the hospital record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as Sepsis, 
unspecified organism. 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 an additional amount for the 
inpatient care. Our reviewer says that the principal diagnosis code is not supported. Our physician reviewer 
found the provided documentation does not include any clinical or laboratory evidence of sepsis. Therefore, the 
reviewer found that the principal diagnosis code is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for the acute inpatient hospital care provided from August 1, 2021, to August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve cardiac imaging. You say that there are conditions that will enhance the 
possibility of a false positive. You also say that since the baseline echocardiogram (ECG) is abnormal, a 
Lexiscan stress test is recommended. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that that cardiovascular nuclear imaging is indicated for 
specific situations. 
 
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 cardiac imaging. Our reviewer says that 
the requested cardiac imaging is not medically necessary. Our physician reviewer found the EKG provided 
with the appeal does not support that there are uninterpretable or equivocal ECG changes caused by drugs, 
bundle branch block, or left ventricular hypertrophy, as required by the LCD. The medical record does not 
demonstrate the enrollee has any indication listed in the above LCD. Therefore, the reviewer has determined 
that the requested service is not medically necessary based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hallux valgus correction (28298) provided on July 14, 
2021. 
 
You asked the Plan to pay for the hallux valgus correction (28298). You say that the physician charges were 
reported appropriately, and the services are supported by the medical documentation. You say that the 
physician should be properly reimbursed for his services. The Plan denied your request. The Plan says 
procedure code 28112 has been paid. The Plan also says that procedure code 28298 is not supported by 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 28298 is correction, hallux valgus (bunionectomy), with 
sesamoidectomy, when performed; with proximal phalanx osteotomy, any method. 
 
 
  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 hallux valgus correction (28298). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the operative report does not include enough information to confirm this procedure was performed per the 
NCCI Policy Manual. The documentation supports a bunionectomy, however the remaining criteria in the code 
description 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 hallux valgus correction (28298) have not been met. Therefore, we decided 
that the Plan does not have to pay for the hallux valgus correction (28298) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional acupuncture visits. 
 
You asked the Plan to pre-approve 6 additional acupuncture visits. You say that you are in severe pain in your 
lower back. The Plan denied your request. The Plan says 12 visits were approved per Medicare guidelines and 
the additional 6 visits remain denied.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, only 12 acupuncture visits in a 90-day period are 
covered. Therefore, we decided that the Plan does not have to pre-approve 6 additional acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee needs this service since he has 
chronic respiratory failure with hypercapnia and this DME is to help him with that. The Plan denied your 
request. The Plan says the enrollee does not meet the medically reasonable and necessary 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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe complex sleep apnea. Neither CPAP nor BiPap with a backup rate were 
successful in adequately treating the OSA, with high residual AHI. The enrollee has been doing well on a ventilator with AVAPS-AE during sleep.  But AVAPS-AE can be provided via BiPap, at less cost to the 
enrollee, and it appears this has not been tried. The enrollee does not have a diagnosis for which Medicare 
covers a ventilator (severe COPD with CO2 retention, thoracic restrictive disease, or neuromuscular disease). 
Medicare does not pay for a ventilator when used as BiPap and the requested home ventilator is 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee can tolerate this drug with 
no substitutions. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Synthroid tablets.  
 
Benefits for self-administered drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Shoulder elbow wrist hand orthosis, (L3960) provided 
August 4, 2021. 
 
You asked the Plan to pre-approve the orthosis. You say that you have attached all the supporting 
documentation. Please reprocess the claim. The Plan denied your request. The Plan says the service does not 
meet the requirements. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the enrollee has not had recent surgery or a recent injury. The documentation 
doesnt support that the joint is unstable or that there is joint laxity.   
The requested upper extremity orthosis is 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Shoulder elbow wrist hand orthosis, (L3960) provided August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve replacement of an ILR. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the requested replacement ILR is not necessary as the enrollee has no 
symptoms and no heart rhythm abnormalities. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that an ILR is used when syncope is thought to be cardiac-
related, but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom memory 
loop recorder. 
 
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 replacement of an ILR. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested authorization for explant of the patients old ILR 
and placement of a new ILR is medically necessary. The patient has a history of atrial fibrillation and stroke in 
the past, with no arrhythmias detected over the past three years. There is no documentation provided to suggest 
a continued need for an ILR. In summary, there is insufficient documentation to support the medical necessity 
for insertion of an ILR in this patients 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 replacement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the replacement of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) guidance for placement of 
radiation therapy fields (77014) provided on April 8, 2021. 
 
You asked the Plan to pay for CT guidance services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this charge is incidental to another service 
billed. 
 
The Plan must follow Medicare rules. 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. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the computed tomography (CT) 
guidance for placement of radiation therapy fields (77014) provided on April 8, 2021, have been met. In this 
case, no medical records were provided to corroborate the billed services. Without these medical records, we 
cannot determine if Medicare coverage criteria were satisfied.  Therefore, we decided that the Plan does not 
have to pay for the computed tomography (CT) guidance for placement of radiation therapy fields (77014) 
provided on April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 15 additional PT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says the additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 15 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the provided documentation indicates that the enrollee has 
had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The reviewer found that the 
enrollee has maintained his ambulatory status from prior PT and is independent in a home exercise program. 
The requested services are not part of a maintenance program, and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the 
requested additional PT visits 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 15 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 Antigen Home Test Kit. 
 
You asked the Plan to pay for a COVID-19 Antigen Home Test Kit. You say that you heard on the news that 
this would be covered. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a COVID-
19 Antigen Home Test Kit is an OTC item. Therefore, we decided that the Plan does not have to pay for a 
COVID-19 Antigen Home Test Kit.