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

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that Please consider this urgent request to 
provide a non-invasive ventilator for the enrollee. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in AVAPS mode with Auto EPAP that could be delivered by BiPAP is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe chronic 
obstructive pulmonary disease with a recent exacerbation. Arterial blood gas in the hospital was consistent with 
acute on chronic hypercarbic respiratory failure. Arterial blood gas in 2021, apparently done while stable, 
showed mild CO2 retention. This enrollee would likely benefit from bilevel positive airway pressure (BiPAP) 
with average volume-assured pressure support (AVAPS) during sleep.  This has not been tried and failed. 
Medicare does not cover a home ventilator when used as 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this service cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the device is not covered for the documented diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 The records shows that the enrollee was provided an electrical stimulator indicated for pain relief and muscle 
rehabilitation. The records do not indicate the intended use of the device, whether for neuromuscular 
stimulation or transcutaneous stimulation. The physical therapy records do not show that the device was 
ordered as part of the enrollees treatment plan. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the electrical stimulator supplies provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11981 billed for date of service January 14, 
2022. 
 You asked the Plan to pay for procedure code 11981. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 11981 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 11981 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 11981 billed for date of service January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the testing is not covered. 
 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. In this case, there are no medical records from the treating physician 
that shows the testing will impact clinical managemnet. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on March 23, 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 are a fall risk after your surgery and inpatient 
rehabilitation is medically necessary for you to return home. The Plan denied your request. The Plan says the 
criteria for approval of inpatient rehabilitation has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies or an intensive rehabilitation therapy program. While the medical record supports that you would 
benefit from physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in an alternate and low intensity setting, such as in a skilled 
nursing facility or in-home with 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone-growth stimulator (E0747). 
 
You asked the Plan to pre-approve an electrical bone-growth stimulator. You say that the requested treatment is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 an electrical bone-growth stimulator. 
Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our 
physician reviewer found that the provided formal X-rays of the right foot have findings consistent with 
progressive healing of the fracture. The X-rays of September 1, 2022, noted anatomic alignment of the healing 
fracture of the shaft of the fourth proximal phalanx and the X-rays of November 1, 2022, note that there is 
interval partial osseous healing of this fracture. There is limited published, large-scale, long-term peer-
reviewed literature that shows electrical bone-growth stimulators to be an effective and/or safe treatment for the 
noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical bone-growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone-growth stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy service provided on July 20, 2022. 
 
You asked the Plan to pay for medical nutrition therapy service. You say that this should be covered. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy service provided on July 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on August 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was done in the enrollee's best interest. 
The Plan denied your request. The Plan says that the testing will not directly impact clinical management. 
 
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. 
 
We looked at the file and the rules. The records provided show that the services at issue were provided in 
California. The Local Coverage Determination, L35000, the Plan used in their decision to deny service is not 
binding in this case. The rule does not have Medicare Part B jurisdiction where the services were provided. No 
other valid denial rationale was presented by the Plan. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for the lab testing services provided on August 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: 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 return 
home independently, The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in other settings 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unspecified iron 
deficiency anemia. She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on April 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on July 7, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the genicular nerve block 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 pay for the genicular nerve block. Our reviewer says 
that the genicular nerve block is not considered medically reasonable and necessary. Our physician reviewer 
found this is considered experimental/ investigational. Therefore, the procedure was not medically reasonable 
and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for a genicular nerve block provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation for ear, nose, and throat (ENT) conditions 
at a tertiary care facility. 
 
You asked the Plan to pre-approve a consultation at a tertiary care facility. You say that you need this service. 
The Plan denied your request. The Plan says the requested services can be provided at a lower level of care. 
 
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 consultation at a tertiary care facility. 
Our reviewer says that the requested consultation at a tertiary care facility is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the plan has 
available and adequate services available for the enrollee. The reviewer found that the record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 consultation at a tertiary care facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation for ear, nose, and throat (ENT) conditions at a 
tertiary care facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy services provided on August 3, 
2022. 
 
You asked the Plan to pay for the hyperbaric oxygen therapy services. You say that you are requesting 
reconsideration as you say these are pre-approved services for the hyperbaric therapy. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that health plans must ensure that services are provided 
when 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 pay for the hyperbaric oxygen therapy services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found Medicare guidelines 
require a Wagner Grade III ulcer or worse in the setting of diabetic ulcer treatments to meet criteria for 
hyperbaric oxygen therapy. The records do not show that the enrollee has any evidence of any other qualifying 
condition such as a severe infection, acute trauma, or acute ischemia. The service does not meet any of the 
limitations/exclusions for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the hyperbaric oxygen therapy services have not been met. Therefore, we 
decided that the Plan does not have to pay for hyperbaric oxygen therapy services provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minute man procedure (22612, 22840). 
 
You asked the Plan to pre-approve the minute man procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the minute man procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental and more research is needed to show 
safety and efficacy. 
 
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 minute man procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the minute man procedure (22612, 22840).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88172 billed for date of service February 
21, 2022. 
 You asked the Plan to pay for procedure code(s) 88172. You say that the service was coded correctly. The Plan 
denied your request. The Plan says the test must be billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88172. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with CPT code 88172. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88172 billed for date of service February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot make it to the restroom. The 
Plan denied your request. The Plan says the items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
We looked at the file and the rules. While incontinence supplies may be appropriate in this case, neither the 
Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-
approve incontinence supplies.