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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. 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 is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal 
evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional 
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy (29823) provided on October 28, 
2021. 
 
You asked the Plan to pay for the shoulder arthroscopy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign bodies). 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the shoulder arthroscopy. Our reviewer says that CPT code 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report does not support an extensive debridement in 3 or more discrete structures where not other work was 
performed. The operative report documents "Arthroscopic shaver was brought in. Labral tear was debrided as 
well the chondroplasty performed of the humeral head. There was some tendinopathy involving the 
supraspinatus which was debrided as well."  Therefore this procedure would be inclusive to the primary 
procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pay for the shoulder arthroscopy (29823) provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ostomy supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that substitutions or generics do not work. The Plan 
denied your request. The Plan says the supplies are available with an in-network provider. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve ostomy 
supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable bed (E1399). 
 
You asked the Plan to pre-approve an adjustable bed. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve e medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an adjustable bed (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
provider is out-of-network with the Plan and the enrollee can be treated by an in-network chiropractor. 
 
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 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system (PERS). 
 
You asked the Plan to pre-approve personal emergency response system. You say that if there is an emergency 
this device will help the enrollee to call someone. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not live alone and is not left home alone for 
long periods of time. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Although the 
Plan offers coverage for personal emergency response systems (PERS), this benefit is provided through 
Medicaid coverage and is not included in the Plans Medicare coverage. Therefore, we decided that the Plan 
does not have to pre-approve a personal emergency response system (PERS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) provided on January 
25, 2022 
 
You asked the Plan to pay for the hearing aid fitting/checking. You say that when you picked up your hearing 
aid your insurance would not pay anything, and you are wondering if this is correct. The Plan denied your 
request. The Plan says your coverage does not provide for hearing aid services when they are not performed by 
a Plan hearing aid vendor. The Plan also says that you contacted the Plan for benefits on January 13, 2022 and 
were advised that if you get a hearing aid that is not a plan approved hearing aid, it will not be covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are the Plan's approved hearing aid brand.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid fitting/checking have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aid fitting/checking (V5011) provided on January 25, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (E1399). 
 
You asked the Plan to pre-approve a recliner chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. 
 
  
 
 Therefore, we decided that the Plan does not have to pre-approve a recliner chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you have diabetes, 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 the 
requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and related accessories. You say that the power 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home mechanical ventilator 
 
You asked the Plan to pre-approve the home mechanical ventilator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the requested device would be used in a BiPAP mode 
that could be provided with a BiPAP (E0471) device with AVAPS added to assure adequate tidal volumes. 
 The Plan must follow Medicare rules. The rules say that ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home mechanical ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home mechanical ventilator
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vaginoplasty and gender affirmation surgery. 
 
You asked the Plan to pre-approve the vaginoplasty and gender affirmation surgery. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 vaginoplasty and gender affirmation 
surgery. Our reviewer says that  Our reviewer found  
 
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 vaginoplasty and gender affirmation surgery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the vaginoplasty and gender affirmation surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical visit provided on June 15, 2021. 
 
You asked the Plan to pay for a medical visit. You say that the services at issue 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 multiple medical visits on the same day in the 
same revenue center may be submitted on separate claims. Hospitals should report condition code G0 on the 
second claim. 
 In this case, multiple medical visits were reported on the same date of service. The claim at issue in this case is 
the second claim but was not billed with condition code G0. Based on this information, we decided that 
Medicare rules for coverage of a medical visit have not been met. Therefore, we decided that the Plan does not 
have to pay for a medical visit provided on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on September 10, 2021, 
through September 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient care was medically necessary. The Plan denied your request. The Plan says that there is 
no documentation of cardiac arrhythmia. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was a then 74 yo female with a history of diabetes mellitus, hypertension, coronary 
artery disease, gout, and degenerative joint disease who presented to the emergency department with orthostatic 
hypotension, weakness and syncope. She had orthostatic blood pressure changes.  The record shows that at the 
time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital 
care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on September 10, 2021, through September 11, 2021.  
 
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 pay for hospital discharge day management (99230) provided on 
September 18, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that this service was billed 
correctly. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation to 
support that hospital discharge day management was provided for 30 minutes or more on the date in question. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99230) provided on September 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a cardiac PET scan. You say that this imaging is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested cardiac PET scan is subject to the 
criteria listed 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 a cardiac PET scan. Our reviewer says 
that the requested cardiac PET imaging service is not medically reasonable and necessary. Our physician 
reviewer found the enrollee is a 67-year-old man with history of hypertension and chest pains. The enrollee's 
provider requests authorization for cardiac PET scan to assess myocardial viability and blood flow. The guidelines do not support the use of cardiac PET imaging in this role. Other modalities of stress testing have 
not been performed in this patient. As a result, at this time cardiac PET scanning would not be considered 
medically reasonable and necessary in this patient's clinical management. 
 
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 cardiac PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cardiac positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plan has no contractual obligation to cover services that are not medically 
necessary or that do not meet Medicare criteria for coverage. 
 
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 ventilator. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee 
was previously treated with bilateral positive airway pressure (BiPAP), but this was changed to a Trilogy 
ventilator in 2020 because a sleep study with capnography showed some oxygen elevations. This data is not provided. There is no arterial blood gas study done while stable showing CO2 retention. There is no evidence 
of BiPAP failure. 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.