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

 
We decided that the Plan does not have to pre-approve removal of knee cartilage using an endoscope. 
 
You asked the Plan to pre-approve removal of knee cartilage using an endoscope. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 removal of knee cartilage using an 
endoscope. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
removal of knee cartilage using an endoscope, in this case, is not medically reasonable or 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 removal of knee cartilage using an endoscope have not been met. Therefore, we 
decided that the Plan does not have to pre-approve removal of knee cartilage using an endoscope.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage, per statute miles (A0425HH) and 
ambulance service, basic life support, non-emergency transport, (A0428HH) provided on July 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. You state the 
enrollee was not transported round trip on this date of service; therefore, the transport would be excluded from 
diagnosis-related group (DRG) inpatient billing and payable by the insurance directly. The Plan denied your 
request. The Plan says they denied this charge because the claim is inappropriately coded based on the code 
definition or standard coding guidelines. The Plan states the enrollee does not owe this amount. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the ambulance services have not been met. The ambulance services 
are covered by Part A, because the enrollee was discharged from one hospital to another. Both facilities are 
different campuses of the hospital, so it is considered patient transportation. Therefore, we decided that the Plan 
does not have to pay for the ground mileage, per statute miles (A0425HH) and ambulance service, basic life 
support, non-emergency transport, (A0428HH) provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that a ventilator is medically necessary for the 
enrollee to stay alive. The Plan denied your request. The Plan says this request for a home mechanical 
ventilator set in targeted tidal volume (TTV), volume-assured pressure support (VAPS) mode with Auto-
expiratory positive airway pressure (EPAP) 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 the home ventilator. Our physician 
reviewer found there is no documentation of failure of BiPAP.  This enrollee may benefit from BiPAP with 
average volume-assured pressure support (AVAPS), if compliance can be achieved. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that after thoroughly discussing all treatment options 
available with the enrollee, he is electing to do IMRT. Due to mitigating factors such as tissue mobility, tumor 
size, location of the lesion, prospective outcome, and potential need for secondary attempts to heal the 
cancerous lesion and local wounds, it was determined that IMRT is medically necessary for the enrollee. The 
enrollee does not want to pursue any surgical options to avoid extensive surgery and the associated risks such 
as nonhealing ulcer and infection. The Plan denied your request. The Plan says the guideline specifically states, 
daily imaging is neither necessary nor useful when treating with electron beam, ELS, or skin surface 
brachytherapy. Therefore, IGRT is not medically necessary in this clinical scenario. The requested service 
remains denied due to lack of medical necessity for the service. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee underwent a full body skin examination on February 27, 2023. Multiple biopsies 
were obtained by shave method. The final diagnosis on the nasal tip was squamous cell carcinoma in-situ 
(Bowen's disease). There are multiple treatment options for Bowen's disease, including surgical excision, 
curettage and electrodesiccation, photodynamic therapy, cryotherapy, topical fluorouracil, and imiquimod. 
There is insufficient high-quality evidence to support the use of IGRT with daily ultrasonic guidance for 
placement of radiation therapy fields in this 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) (G6001).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing services provided on November 7, 2022. 
 
You asked the Plan to pay for diagnostic testing services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says that the provider should bill the facility. 
 
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. Though it is true that the TC cannot be paid in the facility setting, the 
documentation shows that only the professional component was billed. The services were billed with modifier     
-26 for the professional component. There is no reason that the professional component cannot be paid in the 
hospital outpatient setting. Therefore, we decided that the Plan has to pay for diagnostic testing services 
provided on November 7, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services billed with code 93923 provided on 
September 8, 2022. 
 
You asked the Plan to pay for testing services provided. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure code. 
 
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. We find that the imaging report that was submitted for review does 
not match the imaging at issue on this claim. As such, we cannot determine if the diagnosis code is supported. 
Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of testing services provided have been met due to invalid medical records. 
Therefore, we decided that the Plan does not have to pay for testing services billed with code 93923 provided 
on September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that to optimize preventative medicine therapy 
for chronic respiratory failure for the enrollee consequent to advanced chronic obstructive pulmonary disease 
(COPD) and a paralyzed diaphragm, you are prescribing daily, continuous, and intermittent use of mechanical 
volume ventilation. Daily use of mechanical ventilation improves the enrollee's overall function, quality of life 
and prevents a rapid decline in health and hospital re-admission. The Plan denied your request. The Plan says 
the request for a home mechanical ventilator set in "volume assist control" mode with Auto-EPAP (AE) that 
could be delivered by 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure with a paralyzed diaphragm.  The provided medical records document no compelling 
argument for the use of a home ventilator over a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not clarify why the out of network device is medically 
necessary over a device supplied by an in-network equipment supplier. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD, severe advanced emphysema, chronic respiratory failure with hypoxia and hypercapnia. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-
EPAP (AE) that could be delivered by 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary. Provided records document that the 
home ventilator is being requested for use in a volume assured pressure support (VAPS) mode with auto-
titration (AE) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate.  As stated in the Local Coverage Determination (L33800): "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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is intended to diagnose 
and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
Typically, testing will require from four (4) to six (6) hours to perform, including administration, scoring and 
interpretation. 
 
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 neuropsychological testing. Our 
reviewer says that the requested testing is not medically necessary. Our physician reviewer found the proposed 
services involve "brain mapping". This is primarily a technology in which a computer automatically does the 
calculations of the patient's function. It does not necessarily require neuropsychological testing evaluation 
services by physician or other qualified health care professional including integration of patient data, 
interpretation of standardized scoring and does not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical procedure coded as 40845, 21127, 
21209, 41830, 21025 and 21215 provided on July 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical procedure. You say that please reconsider the payment. The Plan 
denied your request. The Plan says the request to use an out of network provider does not meet the 
requirements for approval. Under Medicare guidelines, the request is not medically necessary 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 surgical procedure. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found that the 
conditions for out of network service were not documented therefore, the criteria for coverage have not been 
met. 
 
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 surgical procedure have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the surgical procedure. Therefore, we decided that the Plan 
does not have to pay for the outpatient surgical procedure coded as 40845, 21127, 21209, 41830, 21025 and 
21215 provided on July 13, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a heavy-duty mattress. 
 
You asked the Plan to pre-approve a heavy-duty mattress. You say that you need this mattress. You say that the 
middle of your current bed sinks in the middle. You also say that you are very uncomfortable. The Plan denied 
your request. The Plan says that the item is not covered. 
 
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. Specifically, the file does not support that the Plan has definitively proven that 
they have exhausted all efforts to get records to support the denial Therefore, we decided that the Plan has to 
pre-approve a heavy-duty mattress.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for September 20, 2022. 
 
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 procedure code 99223 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99223 
is not supported. Our reviewer found the enrollee was evaluated for complaints of shortness of breath and fever. The records do not support that there was a comprehensive history and a comprehensive exam but there 
was no medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for September 20, 2022.