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

 
We decided that the Plan does not have to pre-approve a new portable gaseous oxygen system and stationary 
concentrator. 
 
You asked the Plan to pre-approve a new portable gaseous oxygen system and stationary concentrator. You say 
that the records provided support the need for the requested items. The Plan denied your request. The Plan says 
the enrollee has had oxygen since May of 2019 and that the vendor is required to provide contents and service 
for months 37-60. The Plan says that the enrollee can then request new oxygen equipment rental at 60 months. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 new portable gaseous oxygen system 
and stationary concentrator Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the enrollee has had home oxygen since 2019.  3 years of rental have been paid, and the vendor 
is responsible for providing service to the equipment for the remaining 2 years of its life.  This enrollee does 
need continued home oxygen but does not require new replacement equipment at this time. A new portable 
gaseous oxygen system and stationary concentrator is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a new portable gaseous oxygen system and stationary concentrator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a new portable gaseous oxygen 
system and stationary concentrator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services received on February 24, 2022 and February 
25, 2022. 
 
You asked the Plan to pay for the services. You say that there appears to be a mistake in the understanding of 
the urgency of services when you had a stroke. The Plan denied your request. The Plan says that the type of bill 
indicates a non-payable confinement. 
 
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. The plan has not substantiated their denial. The type of bill is 110, which 
indicates that the stay would not be covered, and the plan's contract provider is liable. You are not able to held 
responsible for these services, as the provider is liable, and the services would meet the criteria for being 
emergent. A prudent layperson would believe that there was serious jeopardy to your heath, as you were having 
a stroke. Therefore, we decided that the Plan has to pay for inpatient hospital services received on February 24, 
2022 and February 25, 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 pay for the continuous positive airway pressure (CPAP) device 
purchased on February 3, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that you were under the impression this would be 
covered. The Plan denied your request. The Plan says this equipment was purchased from a provider not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device purchased on February 3, 2022.
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 received oral medications, had 
stable vital signs and her lungs were clear. There are no identifiable skilled nursing service needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis.  She does 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (0037U) provided on November 
30, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this testing is statutorily non-
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services (0037U) provided on 
November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (LAAC) (33340, 
93355). 
 
You asked the Plan to pre-approve LAAC. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the requested is not a covered benefit because the records do not 
demonstrate participation in shared decision making or confirmation that the enrollee is a suitable candidate for 
short term anti-coagulation. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
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 LAAC. Our reviewer says that the 
requested service is not reasonable or medically necessary. Our physician reviewer found there is no 
documentation of performance of an evidence-based shared decision-making interaction on anticoagulation. As 
such, guidelines would not support implantation of a LAAC 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 LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Left Atrial Appendage Closure (LAAC) (33340, 93355).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81599) provided February 1, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this testing was not medically necessary and is non-covered. 
 
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 genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the guidelines of the National Comprehensive Cancer Network do not recommend the 
DecisionDx-SCC gene expression test as part of the evaluation or treatment of patients with squamous cell skin 
cancer. 
 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81599) provided February 1, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF 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 physician reviewer 
found the enrollee qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. 
The enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below their 
baseline. The enrollee has made some progress while at the acute care hospital (ACH). A period of daily skilled 
services is required to establish a maintenance program and/or to prevent deterioration of the enrollees 
condition. As a practical matter, services cannot currently be provided 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (S9123) provided on April 11 to April 
17, 2021. 
 
You asked the Plan to pay for home health services. You say that the requested home health services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9123 is not valid for Medicare purposes. Home health services should be billed with G or Q codes. 
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 pay for home health services (S9123) provided on 
April 11 to April 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for laboratory testing related to 
treatment of end-stage renal disease is bundled into dialysis services and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve a complete lower denture. You say that you lost your bottom dentures and 
need a replacement. The Plan denied your request. The Plan says the service is a covered benefit, but you have 
exceeded the frequency limit of one every 5 years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete lower denture have not been met. Specifically, the record shows that you had exceeded 
the frequency limit prior to this service on February 6, 2020. Therefore, we decided that the Plan does not have 
to pre-approve a complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an appeal for the 
denied services with the medical records attached. The Plan denied your request. The Plan says they denied 
transfer to LTACH because records do not show that the enrollee needs continued medical treatments that can 
only be given in a hospital setting. The enrollee continued care needs include, daily wound care, monitoring of 
the enrollee's wounds and therapy. When the enrollee is ready to leave the hospital, the enrollee can safely 
receive this care in another setting, such as a Skilled Nursing Facility (SNF) or at home with home health 
services or outpatient setting if appropriate. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift. 
 
You asked the Plan to pre-approve a seat lift. You say that the requested item is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the criteria 
listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a seat lift have not been met. Specifically, the available medical records do not document that you 
are completely incapable of standing up from a regular armchair or any chair in your home. Therefore, we 
decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart permanent cardiac contractility 
modulation (CCM) system. 
 
You asked the Plan to pre-approve Optimizer Smart CCM system. You say that clinical findings support the 
medical necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because this is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Optimizer Smart CCM system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found multiple observational studies suggest a clinical benefit to CCM. While the 
clinical studies led to Food & Drug Administration (FDA) approval in 2019, CCM remains the subject of 
multiple studies examining long-term efficacy as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart CCM system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Optimizer Smart permanent cardiac contractility modulation (CCM) 
system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominal surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON abdominal surgery. You say that the records provided support the 
need for the requested surgery. The Plan denied your request. The Plan says there are providers within the 
network who can help with the requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
abdominal surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the codes in 
question are assigned a PC/TC indicator of 1. The services were billed with place of service 22. The 
professional interpretation was furnished in the same payment locality from where the technical component 
was furnished. In this case, modifier -26 is required for payment of these services. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).