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

 
We decided that the Plan does not have to pre-approve reduction mammoplasty. 
 
You asked the Plan to pre-approve reduction mammoplasty. You say that you have a ruptured implant which 
could be damaging. The Plan denied your request. The Plan says the record shows you do not have significant 
symptoms despite conservative management that requires removal of breast tissue. 
 
The Plan follows Medicare rules. Medicare rules state that reduction mammoplasty is covered if certain 
conditions are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve reduction mammoplasty. Our reviewer 
says that you do not meet criteria for this surgery. Our physician reviewer found you had breast implants placed 
in 1984 for cosmetic reasons. You had a recent mammogram that showed implant rupture and are feeling pain 
in your chest. You do not meet any of the coverage indications for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reduction mammoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve reduction mammoplasty.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on December 7, 2022. 
 
You asked the Plan to pay for genetic testing. You say that your physician and medical facilities related to 
treatment stated that they had received no inquiries regarding a claim denial or pre-authorization denial. The 
Plan denied your request. The Plan says that the requested test is not reasonable and necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for genetic testing by a contract provider. The file does not show that the Plan provided 
notice that genetic testing would not be covered prior to the services being provided. Under Medicare rules, this 
means genetic testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
genetic testing provided on December 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that the enrollee needs this 
type of bed. The Plan denied your request. The Plan says the enrollee does not meet criteria for this bed. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met:  
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
We looked at the file and Medicare rules. The medical records provided show that the enrollee weighs less than 
350 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide 
hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty 
extra wide hospital bed (E0303).
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) A0428 and A0425. We 
decided that the Plan does not have to pay for the services described by procedure code(s) A0170.  
 
You asked the Plan to pay for ambulance transportation services (A0428, A0425 and A0170) provided on 
October 28, 2022. You say that the enrollee was discharged from one facility before this transport was provided 
and was admitted to a new facility after arrival. Therefore, these services should be separately payable. The 
Plan says that the payment for these services would be included in the hospital payment. 
 
We decided that the Plan has to pay for the services described by procedure code(s) A0428 and A0425.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no documentation to support that these 
services would be included in the payment to any facility. There is no evidence that the enrollee maintained 
inpatient status with one facility on the date in question or that the enrollee was transported to a different 
building within the same hospital/facility group. These services are not supported as being inpatient 
transportation. The Plan's denial is not substantiated, and these services should be separately payable based on 
the documentation provided. Therefore, we decided that the Plan has to pay for the services described by 
procedure code(s) A0428 and A0425.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
A0170. 
 
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 A0170 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0170 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services described by procedure code(s) A0170 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) A0170. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that it is very difficult for you to get in and out 
of the bathtub. You say that you you have arthritis and back pain. You say that The Plan denied your request. 
The Plan says the requested item is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for a faster 
recovery. The Plan denied your request. The Plan says you do not meet all the requirements for admission to an 
IRF. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
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 the enrollee exceeds criteria for LTACH 
services. You also say the care and services required by the enrollee exceeds the clinical capabilities of all 
lower levels of care in the geographical region. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require additional short-term additional acute care services that can safely be administered at the current facility until more appropriate for a lower level of care. There are no services at the LTACH that the patient requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided on January 4, 2023. 
 
You asked the Plan to pay for home infusion services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the needed documentation was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of home infusion services have been met. 
Specifically, no supporting records were submitted to support payment of this claim. The Plan requested 
supporting records but none were submitted. Without supporting records, we cannot determine whether the 
services at issue are payable as they have been billed on this claim. Therefore, we decided that the Plan does 
not have to pay for home infusion services provided on January 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that your surgeon stated you can go to the SNF after 
surgery. The Plan denied your request. The Plan says you do not meet the requirement for a SNF admission. 
 
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 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 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) provided on July 
22, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not on hospice on the date in 
question. The Plan denied your request. The Plan says the enrollee was enrolled in hospice care from July 22, 
2022, through July 25, 2022. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) provided on July 
22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional month of negative pressure wound therapy (NPWT). 
 
You asked the Plan to pre-approve the additional month of NPWT. You say that this treatment must continue 
as it has been helping with wound healing. The Plan denied your request. The Plan says that NPWT cannot be 
covered after four months of use. 
 
The Plan follows Medicare rules. Medicare rules say that, while NPWT use is generally limited to four months, 
the appeal process may be used to argue for coverage of additional month, when proven to be reasonable and 
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 additional month of NPWT. Our 
reviewer says that the documentation supports the medical necessity of an additional month of NPWT. Our 
physician reviewer found the enrollee is a 63-year-old female with a surgical abdominal wound who had been 
using an NPWT pump for 4 months with measurable improvement. An additional month of NPWT therapy 
(wound VAC) was requested which is supported in the provided documentation as the enrollee is improving 
due to use of this device. An additional month of NPWT therapy is supported and 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 additional month of NPWT have been met. Therefore, we decided that the 
Plan has to pre-approve an additional month of negative pressure wound therapy (NPWT).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF will give the enrollee the best 
opportunity to improve function and return to their baseline. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements for admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
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 necessary. The Plan 
denied your request. The Plan says the ventilator is not 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 there are no pulmonary function tests to confirm airways obstruction or assess severity. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention. If this 
enrollee does have chronic CO2 retention, may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and 
failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing (0339U) provided on January 4, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the SelectMDx testing by a contract provider. The file does not show that the plan 
provided notice that the SelectMDx testing would not be covered. Under Medicare rules, this means the 
SelectMDx testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
SelectMDx testing (0339U) provided on January 4, 2023.  
 
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.