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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode which could 
be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for July 31, 2022, to August 1, 
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 99233 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 99233 is According to Medicare, CPT code 99233 can be 
used for subsequent hospital care, per day, for the evaluation and management of a patient with at least 2 of the 
3 key components: a detailed interval history, a detailed examination, medical decision making of high 
complexity.  Usually, the patient is unstable or has developed a significant complication or a significant new 
problem and takes approximately 35 minutes at the bedside or the patients hospital floor or unit. In this case, the documentation doesnt support the CPT code 99233. The documentation available for review 
does not support the encounter developed a significant complication or that medical decision making of high 
complexity was needed. 
 
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 99233 
is not supported. Our reviewer found that the documentation does not support the billing of code 99233. The 
documentation does not support that the encounter included a significant complication or 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 99233 billed for July 31, 2022, to August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) with heated humidifier (E0562). 
 
You asked the Plan to pre-approve the CPAP device with heated humidifier. The Plan denied your request. The 
Plan says the coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that continued CPAP use is covered for the indications 
established in the applicable LCD. 
 
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 CPAP device with heated 
humidifier. Our reviewer says that the requested CPAP device with heated humidifier is not medically 
reasonable and necessary. Our physician reviewer found that this does not meet Medicare minimum 
requirements of at least 70% of days with at least 4 hours of use. There are no recent notes of clinical visits or 
attempts to address the compliance issue.  Since the device is not being used enough to be effective, the 
coverage criteria are not 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 CPAP device with heated humidifier have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) with heated humidifier (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services (99239) provided on 
May 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not 
show that more than 30 minutes of discharge management services were provided on the date of service in question. 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 the discharge management services (99239) 
provided on May 31, 2022.
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 enrollee's medical management and rehabilitation 
needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says the enrollee's records do not show you need to be seen by a rehab doctor at least 3 times a week 
or an intensive team for your care, services needed can be provided safely in other settings, a skilled nursing 
facility. 
 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's documents has no complex functional impairments are specified thus 
the complexity of nursing, medical and rehabilitation needs would not be expected to 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for an office or other outpatient visit provided on  
October 28, 2022. 
 
You asked the Plan to reimburse you for the office or other outpatient visit. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that you received non-emergent/urgent 
services in another state and there is no passport benefit in place. 
 
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 Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to reimburse you for an office or other 
outpatient visit provided on October 28, 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: 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 enrollee has multiple comorbidities 
including severe acute on chronic respiratory failure, hypertension, HTN, CHF, DM2, CAD, pacemaker, left 
lung nodule, gout, and recent cardiac arrest due to respiratory failure and failure of BiPAP leading to 
intubation. You also say that the enrollee cannot discharge without volume ventilation. The Plan denied your 
request. The Plan says the records do not show failure of BiPAP. The records show that BiPAP helped the 
enrollee in the hospital. The doctor has requested a NIV in AVAPS mode, which can be met by a BiPAP. The 
request is not medically necessary. 
 
 
 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 COPD with chronic 
CO2 retention, although there are no pulmonary function tests in the medical records to confirm severity.  The 
enrollee was recently hospitalized with pneumonia and an acute exacerbation of COPD, and ABG was 
consistent with acute on chronic hypercarbic respiratory failure. The enrollee suffered a cardiac arrest in the 
hospital with successful resuscitation. After extubation, the enrollee had difficulty complying with BiPAP in 
the hospital. There is no evidence in the record that the enrollee has tried and failed BiPAP at home. The 
enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rotator cuff surgery using an endoscope. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is a lack of large-volume, long-term peer-reviewed outcome studies to support the use 
of superior capsular release as an effective treatment. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
endoscopic rotator cuff surgery (superior capsular reconstruction), 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rotator cuff surgery using an endoscope.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the requesting home health services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented, ongoing, skilled nursing needs. The enrollee has caregivers available to 
help with custodial needs. The requested, ongoing, home health skilled nursing services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on October 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The durable medical equipment was provided in an ambulatory surgical 
center. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the 
home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that after a motor vehicle accident the enrollee requires 
IRF services. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections, two levels. 
 
You asked the Plan to pre-approve injections. You say that the enrollee has expressed interest in repeating 
these injections. You also say that the enrollee reports worsening neck pain. The Plan denied your request. The 
Plan says the requested injections are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary when certain 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 injections. Our reviewer says that the 
requested facet joint injections are not medically necessary. Our physician reviewer found the guidelines 
indicate two medial branch blocks should be performed before radiofrequency ablation (RFA). the reviewer 
found that the enrollee does not have any contraindication to an RFA. Therefore, the reviewer found that the 
requested injections are 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve facet joint injections, two levels.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
20, 2022 to December 13, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee still needed care and assistance The Plan 
denied your request. The Plan says there was no need for skilled nursing services on a daily basis, and the 
enrollee did not require skilled rehabilitation services daily. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there were no identifiable skilled nursing or therapy needs. The enrollee did not 
require skilled nursing or therapy services on a daily basis. The enrollee did 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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 20, 2022 to December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 10, 2022, to 
July 12, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 DRG 193. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with worsening shortness of breath, wheezing and cough, and was treated in the 
hospital. The enrollee did not require high flow oxygen, bilevel positive airway pressure (BiPAP), or ventilator 
support, nor was the enrollee in acute respiratory distress or with significant hypoxia. The definition of acute 
respiratory failure was not met. Therefore, there was insufficient support made in the documentation for acute 
respiratory failure (J96.01). The records therefore support the DRG 194 more.   
 
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 
for inpatient hospital services rendered from July 10, 2022, to July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colostomy supplies received on October 6, 2022. 
 
You asked the Plan to pay for colostomy supplies. You say that you want the Plan to pay for these items. The 
Plan denied your request. The Plan says item or services received from a provider that is not enrolled in the 
Medicare program are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of colostomy supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for colostomy supplies received on October 6, 2022.