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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. His physical function is at or near his baseline. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is to be used for the 
treatment of COPD, obesity, and suboxone use. The Plan denied your request. The Plan says the requested 
device does not meet 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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD with a recent 
exacerbation. ABG when acutely ill suggested acute on chronic CO2 retention, but there is no ABG done as an 
outpatient while stable to confirm chronic CO2 retention. BiPAP has not been tried at home. AVAPS could be 
provided via BiPAP at less cost to you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on June 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test provides actionable results to facility 
the early detection of bladder cancer. The Plan denied your request. The Plan says the testing 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 pay for the testing services. Our physician reviewer 
found that the enrollee with prostate cancer treated with robotic prostatectomy in 2013.  Cancer recurred in 2014 and he was treated with radiation. He has had severe urinary incontinence since then. 
He now has a 5-month history of intermittent gross hematuria. A CT scan was normal. Cystoscopy in January 
2021 shows radiation cystitis of the bladder and prostatic urethra. The CxBladder test is not considered a 
screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still 
be necessary regardless of the results of CxBladder testing. Urinary biomarker tests such as CxBladder give 
significant false-negative results in those with urothelial cancer and are subject to false-positive results in 
others. Accuracy is poor for low-stage and low-grade tumors. The records do not show that the results of the 
testing would impact clinical management in a manner demonstrated in peer-reviewed literature.  
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on June 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need physical therapy services, and you live 
by yourself and do not have anyone to help you. You also say that you are afraid to go home alone as you 
might fall. The Plan denied your request. The Plan says it was determined that you do not meet the criteria for 
admission to a skilled nursing facility. 
 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 services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found You do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography, abdomen. 
 
You asked the Plan to pre-approve a computed tomographic angiography, abdomen. You say that a computed 
tomographic angiography, abdomen is medically necessary. The Plan denied your request. The Plan says a 
computed tomographic angiography, abdomen does not meet the eviCore Peripheral Vascular Disease Imaging 
guidelines. 
 
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 a computed tomographic angiography, 
abdomen. Our reviewer says that a computed tomographic angiography, abdomen is not considered medically 
reasonable and necessary in this case. Our physician reviewer found while aortic aneurysm surveillance is 
generally recommended on the basis of maximal aortic diameter, it is recognized that this is merely a crude 
surrogate marker for rupture risk. Current research explores materials modelling, computational fluid dynamics 
and finite element analysis in order to predict how aneurysms will grow and the potential location and timing 
of rupture. Biological markers are also being investigated to determine whether they are viable measures of 
aneurysm activity for the sake of clinical management. In this case there is no reported abdominal or back pain. There is no specific clinical rationale for the requested computed tomographic angiography, abdomen. The 
review has determined that the requested computed tomographic angiography at issue 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 a computed tomographic angiography, abdomen have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computed tomographic angiography, abdomen 
(74175).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a place of service of 22 (outpatient hospital) is not considered as an appropriate place of service. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider reported Current 
Procedural Terminology (CPT) 85060: Blood smear, peripheral, interpretation by physician with written report 
performed in place of service 22 On-Campus outpatient hospital. In this case, services were billed incorrectly 
per Medicare.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 22, 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 the enrollee's clinical condition meets full inpatient 
acute care rehabilitation criteria. You say that the inpatient rehabilitation stay will improve their overall 
function. The Plan denied your request. The Plan says the enrollee's condition can be treated at a lower level of 
care. 
 
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 enrollee's medical problems are stable and 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. 
 
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 Oral Glucerna Vanilla Nutritional Shakes (CPT code 
B4154). 
 
You asked the Plan to pre-approve the shakes. You say that the shakes are necessary. The Plan denied your 
request. The Plan says orally administered enteral nutrition products, related supplies and equipment will be 
denied non-covered, no benefit. 
 
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 shakes have not been met. Medical records received from your 
primary care provider (PCP) do not document that you are receiving nutrition via tube feedings or by 
intravenous (IV) or injection. Therefore, we decided that the Plan does not have to pre-approve Oral Glucerna 
Vanilla Nutritional Shakes (CPT code B4154).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve Freestyle Libre 2 reader. You say that the Libre 2 has an alert/alarm when 
your blood sugar is low. You have both arthritis and psoriasis and very dry skin. It is painful when you have to 
prick your fingers. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
coverage of Freestyle Libre 2. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre 2 reader have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 reader.
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 you will be able to get dialysis and the 24-hour 
nursing care you need. The Plan denied your request. The Plan says you do not meet the requirements for 
approval. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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 filters for member owned portable oxygen concentrator. 
 
You asked the Plan to pre-approve the filters. You say that you own an Inogen machine, and it stopped working 
because the filters need to be changed. You thought it would be cheaper for the Plan to supply the filters 
instead of the machine. You could not afford to the $100 for the replacement filters. The Plan denied your 
request. The Plan says filters for a member owned portable oxygen concentrator is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 filters have not been met. Therefore, we decided that the Plan does not have 
to pre-approve filters for member owned portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee lives alone with no support in a 
two-level home. The Plan denied your request. The Plan says SNF services are 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 services. Our reviewer says that 
there is no documentation that daily skilled services are required. Our physician reviewer found that the 
provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. Services in the home with home health care or in a long-term care facility on 
a part time basis are more 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the additional trips are 
necessary. The Plan denied your request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
Review of the file shows that you exhausted your 52 trips. The Plan's 2022 EOC states they cover routine 
transportation for up to fifty-two (52) trips every year. The 53rd trip and beyond is not a covered benefit. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (CPT code E0218) 
and pump for water circulating pad (CPT code E0236). 
 
You asked the Plan to pre-approve the items. You say that one authorization got approved for this equipment 
but with wrong location because they do not carry this equipment, the provider has this equipment, and this 
authorization is the one that needs to be approved. The Plan denied your request. The Plan says the items are 
not covered by Medicare or the health plan. 
 
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 items have not been met. The Medicare guidelines say that a 
water circulating cold pad with pump will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve fluid circulating cold pad with pump (CPT code E0218) and pump 
for water circulating pad (CPT code E0236).
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. The Plan denied your request. The Plan says the enrollee's needs 
can be met at a lower level of care. 
 
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 medical problems are stable and 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.  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 portable ramp (E1399). 
 
You asked the Plan to pre-approve a ramp. You say that you are wheelchair bound and your ramp needs to be 
lifted so you can go in and out using your power wheelchair. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a portable ramp (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that both the enrollees primary care 
physician and cardiologist supported the need and medical necessity for the compression garments. The Plan denied your request. The Plan says the requested compression garments is only covered when it is used in the 
treatment of an open venous stasis ulcer. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.