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

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you would like to remain at the 
SNF. The Plan denied your request. The Plan says the continuation of SNF services is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 a continuation of SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (43281) provided on August 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 27, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services (43281) provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for chiropractic treatment provided on 
August 11, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says if you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services for chiropractic treatment provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device and 
supplies, provided on April 6, 2021, to November 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP device and supplies. You say that the items should be covered. The 
Plan denied your request. The Plan says prior authorization must be obtained to receive items out of network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) 
device and supplies, provided on April 6, 2021, to November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory pathogen panel provided to the enrollee on 
March 21, 2022. 
 
You asked the Plan to pay for the panel. You say that the charges are appropriate for the level of acuity and 
intensity of the 
medical services provided as well as the expertise required providing these services. The Plan denied your 
request. The Plan says respiratory pathogen panels of 6 or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panels with more than five respiratory 
pathogens are not covered. 
 
It appears that more than five pathogens were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have 
to pay for a respiratory pathogen panel provided to the enrollee on March 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care, provided on 
May 7, 2022, to May 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the wrong cost share 
was applied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each day one through six for inpatient hospital care.  
 
You have been asked to pay a $300 copayment for each day one through six for the inpatient hospital care. This 
service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the inpatient hospital care, provided on May 7, 2022, to May 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 20930. The Plan denied your request. The Plan says procedure 
code 20930 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services on November 10, 
2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for wound care services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per visit for wound care services.  
 
You have been asked to pay a $200 copayment per visit for wound care services. This item/service falls within 
the Outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
wound care services on November 10, 2021, to November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCD (CPT code E0675) provided from December 8, 
2021, through December 29, 2021. 
 
You asked the Plan to pay for the PCD. You say that the claim should be paid. The Plan denied your request. 
The Plan says the PCD is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Furthermore, Medicare rules say that CMS does not pay 
any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an 
inpatient. Therefore, we decided that the Plan does not have to pay for the PCD (CPT code E0675) provided 
from December 8, 2021, through December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this service is necessary. The Plan denied your 
request. The Plan says admission to the IRF was denied as not meeting criteria and 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for hematuria and radiation cystitis. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 acute IRF admission and services.
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 needs the requested equipment. 
Her hypercapnia is not controlled with a bipap and needs alarms and ventilation that only a ventilator has. She 
is end COPD stage and needs this treatment to not cause any further damage. The Plan denied your request. 
The Plan says the ventilator settings ordered for the home mechanical ventilator could alternatively be provided 
by a BiPAP device with average volume assured pressure support (AVAPS). 
 
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 provided records document the 
enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease. The records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive hereditary pharmacogenomic testing and 
hereditary genetic cardiac testing (CPT code(s): 81241, 81291, 81355) provided on April 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says there is no documentation from the provider documenting the specific drugs being 
considered for use, and no documentation to how the results will specifically impact treatment. 
 
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 laboratory services. Our physician 
reviewer found there is no specific clinical documentation from the provider documenting the specific drugs 
being considered for use, and no documentation to how the results will specifically impact treatment. The 
review has determined that the medical records provided did not meet the requirements listed in the LCD for 
Medicare 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac 
testing (CPT code(s): 81241, 81291, 81355) provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology consultation and report (CPT code 
88323-26) provided on April 1, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the claim is a duplicate. 
 
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 service have not been met. The records submitted do not indicate that two separate services were performed/supported. Therefore, we decided that the Plan does not 
have to pay for the surgical pathology consultation and report (CPT code 88323-26) provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the left sacroiliac (SI) joint 
(codes 64635 and 64636). 
 
You asked the Plan to pre-approve the services. You say that you would like this request to be reviewed as 
medically necessary for the enrollee to have this procedure performed. The Plan denied your request. The Plan 
says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis 
have not been demonstrated in the peer-reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Studies completed say that this procedure does not improve outcomes compared to standard 
treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or 
pulsed radiofrequency, is considered investigational and therefore, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the left sacroiliac (SI) joint (codes 64635 and 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left total shoulder arthroplasty reversal. 
 
You asked the Plan to pre-approve left total shoulder arthroplasty reversal. You say that the requested left total 
shoulder arthroplasty reversal is medically necessary. The Plan denied your request. The Plan says the 
requested left total shoulder arthroplasty reversal 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 left total shoulder arthroplasty reversal. 
Our reviewer says that the requested left total shoulder arthroplasty reversal is not medically necessary. Our 
physician reviewer found the enrollee was being treated for left shoulder rotator cuff arthropathy. She 
presented with continues to have pain and limitations with the left shoulder. The left shoulder pain has 
progressively increased. The pain keeps her up at night, limits her activities and she avoids using it. The exam 
of the left shoulder reveals forward flexion of 150 with good strength, external rotation is 50-60 with good 
strength, and internal rotation to L4 with good strength. She has pain with range of motion. The x-rays of the 
left shoulder show significant arthritis in the glenohumeral joint, there is no joint space remaining on the lateral 
view, humeral head is high riding on the anteroposterior (AP) view, there is acetabularization of the underside of the acromion consistent with rotator cuff arthropathy. 
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures for the left shoulder. Additionally, the imaging studies 
did not corroborate an irreparable rotator cuff tear. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested left (reverse) total shoulder arthroplasty, 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 left total shoulder arthroplasty reversal have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left total shoulder arthroplasty reversal.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 2022. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enclosed walker (CPT code E0144) provided on May 16, 
2022. 
 
You asked the Plan to pay for the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says E0144 is not medically reasonable or necessary. 
 
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 item have not been met. The rules say that the medical 
necessity for a walker with an enclosed frame (E0144) has not been established. Therefore, if an enclosed 
frame walker is provided, it will be denied as not reasonable and necessary. Therefore, we decided that the Plan 
does not have to pay for the enclosed walker (CPT code E0144) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen supply rental. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says no 
further authorizations can be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen supplies are only covered under certain 
medical indications.   
 
We looked at the file and Medicare rules. The file shows that 36 months of rental payments have been 
provided. Oxygen equipment is limited to 36 monthly rental payments. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve oxygen supply rental.