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

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator 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 the home ventilator. Our physician 
reviewer found it is not documented that bilevel positive airway pressure (BiPAP) with a back-up rate or 
volume-assured pressure support have been utilized and failed for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: 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 services are necessary for the enrollee to regain 
maximum function and return home independently. The Plan denied your request. The Plan says the services 
could be provided in another setting. 
 
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 is medically stable. No acute rehab nursing needs are identified or 
documented. While the enrollee may benefit from physical or occupational therapy, the enrollee's rehab needs 
can be provided in a lower intensity and alternate setting such as in 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep apnea oral appliance provided on September 24, 
2022. 
 
You asked the Plan to pay for the oral appliance. You say that this was provided for a covered indication and 
should be paid. The Plan denied your request. The Plan says the criteria for the device are not met. 
 
The Plan follows Medicare rules. Medicare rules say that for enrollees with an AHI of over 30, an oral 
appliance is only covered when there is an intolerance to or contraindication for a PAP device. 
 
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 oral appliance. Our reviewer says that 
the LCD criteria for this device have not been met. Our physician reviewer found the enrollee's AHI/RDI are 
noted to be over 30. There is no evidence that a PAP device was prescribed for the enrollee.  It has not been 
demonstrated that the enrollee is not able to tolerate a positive airway pressure (PAP) device, or that the use of 
a PAP device is contraindicated. 
 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 oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pay for the sleep apnea oral appliance provided on September 24, 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 needs are unable to be met in a lower 
level of care. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in another setting such as a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 functional status does not require intensive rehabilitation. The enrollee 
is functioning near a home care level and ambulating at a home care level. The enrollee does not require 
intensive rehabilitation services. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET of the brain (78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says that the PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our physician reviewer 
found the oncologist's plan is to alternate magnetic resonance imaging (MRI) and PET/ computerized 
tomography (CT) to monitor for recurrence. The exam should be approved. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET of the brain (78608).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 23, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that it is felt that this was coded correctly and 
should be paid. The Plan denied your request. The Plan says this was paid with code 99284 as this more 
accurately reflects the care provided. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services as billed. Our reviewer says 
that the progress note does not support the use of code 99285. Our reviewer found the enrollee has a history of 
hypertension and presented to the ED after a syncopal episode at home. She denied chest pain or palpitations. 
She was evaluated with a history and physical exam, laboratory studies, and an electrocardiogram. She denied 
chest pain or palpitations. The review has determined that the documentation did not support procedure code 
99285. There was no decision making of high complexity. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on October 23, 2022, billed with 
code 99285.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT. You say that you fell and have been having difficulty since. Your 
condition is improving with therapy and requires more sessions. The Plan denied your request. The Plan says 
the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 PT. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the services are not medically necessary. Records do not show that you require 
or that you need continued care to prevent or slow further deterioration. Per chapter 7 your functional status has 
remained stable despite continued skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional physical therapy (PT) visits.
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 needs IRF services in order to get 
stronger to be eligible for a liver and kidney transplant. 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 the member is a 67-year-old female with a medical history including chronic lung disease, diabetes mellitus, liver disease who was admitted to the hospital after a mechanical fall resulted in a 
fractured humerus. She was also diagnosed and treated for bacteremia and resistant ascites from cirrhosis. The 
most recent therapy notes indicate that the member requires minimum assistance for transferring and 
ambulating up to 25 feet. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain her functional status.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says code 99223 is not supported by the medical record. The medical records do 
not support that a comprehensive history was done, so this code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is  Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; a 
comprehensive exam; and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the member is a 67-year-old female without a significant 
past medical history who presented to the hospital with right-sided flank pain. She was diagnosed and treated 
for appendicitis, a urinary tract infection and COVID-19 infection. The admitting history and physical exam was documented on July 9, 2022. There was not a family history included in the evaluation. The member was 
hemodynamically stable. The plan of care included parental antibiotics, IV fluids and surgery. She was 
asymptomatic regarding the COVID-19 infection. The documentation doesn't support that a comprehensive 
history was completed, so the code is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service July 9, 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 you have difficulty walking and prefer to go to an 
inpatient rehab facility rather than into a skilled nursing facility. The Plan denied your request. The Plan says 
the treatment you need can be provided in a lower level of care such as at a skilled nursing facility or at home 
with home health 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 there are no acute rehab nursing needs identified or documented. At the current 
functional level, you do not need intensive therapies.  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 lower intensity and alternate setting such as in 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on July 
24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the requested ambulance service. The Plan denied your request. The Plan says the ambulance transport 
was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our physician 
reviewer found transportation via ambulance from the emergency department to the enrollees residence/care 
facility was not medically necessary. The enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollees condition. A prudent layperson would not believe that immediate medical attention was required for 
someone wo was being discharged from the hospital. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services (A0428 and A0425) provided on July 24, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (code 93971) provided on September 12, 2022.

You asked the Plan to pay for the duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. You say that the services were medically necessary. The Plan denied your request. The Plan says per the CMS Local Coverage Article A57594 (Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies), diagnosis code M25.462 (Effusion, left knee) is not on the list of approved diagnoses for CPT 93971. As a corrected claim with a covered diagnosis has not been received, claim is denying correctly and will be upheld.

The Plan must follow Medicare rules. 

We looked at the file and Medicare rules. The billed diagnosis code M25.462 (Effusion, left knee) is not on the list of the Medicare LCA approved diagnoses for CPT 93971. Based on this information, we decided that Medicare rules for coverage of the duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (code 93971) provided on September 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Illumya (J3245 x 3). 
 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the information we received does not show that the enrollee has tried 
and failed our preferred therapy. 
  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the documentation does not support that Inflectra (Infliximab-dyyb) or Avsola (Infliximab-axxq) would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The enrollee has 
not tried and failed the required drug(s). 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Illumya (J3245 x 3).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on April 26, 2022, billed with codes 
01480-QK-QS and 01480-QX-QS. 
 
You asked the Plan to pay for the anesthesia services. You say that additional payment should be made for 
these services. The Plan denied your request. The Plan says that no additional payment is due. 
 
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 file submitted by the Plan only references one of the two services provided 
on the date at issue. Our decision addresses both codes as both are appealed per the appeal request. The 
rationale is that since more was reimbursed by the primary payer than the Medicare allowable, no further 
payment can be made. However, after primary reimbursement, $73.16 is owed by the enrollee. As the Medicare 
allowable is greater than the amount still owed by the enrollee, the Plan must issue payment for the $73.16. 
Therefore, we decided that the Plan has to pay for the anesthesia services provided on April 26, 2022, billed 
with codes 01480-QK-QS and 01480-QX-QS.  
 
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.