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

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD and 
obesity hypoventilation syndrome. A note from 2020 indicates you have a bipap at home for OHS. There is no 
documentation of COPD with pulmonary function tests, and no documentation of chronic CO2 retention with 
an ABG. There is no documentation of bipap failure, or analysis of compliance with bipap. Bipap with AVAPS 
has apparently not been tried. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current hospital. 
 
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 all medically necessary care is being provided in the current acute care facility. There 
are no services available at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care 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 the LTACH services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs 
can be met at a lower level of 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program.   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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee has type 2 diabetes 
and is not able to tolerate self-monitoring with finger sticks. The Plan denied your request. The Plan says you 
do not meet prior authorization 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 indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on October 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted indicates that nutria-pharmaceutical blend was administered; 
therefore, each component of the blend cannot be billed separately. 
 
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 the denied codes is: 
 
HCPCS J3411: 
 
Injection, thiamine hcl, 100 mg 
 
HCPCS J3415: 
 
Injection, pyridoxine hcl, 100 mg 
 
 HCPCS J3490: 
 
Unclassified drugs 
 
HCPCS J7999: 
 
Compounded drug, not otherwise classified 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure describes "a pre-filled 
syringe containing drugs with a 30 gauge 1.5 inch needle was inserted subcutaneously and observed tracking to 
the correct position as defined in procedure anatomical location above." In this case, medications are pre-mixed 
and would not be reported separately. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on October 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 3, 
2020, through August 1, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the SNF care provided was medically necessary and 
should be paid. The Plan denied your request. The Plan says the rules for SNF care were not met. 
 
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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary. Our physician reviewer found that as of July 3, 
2020, the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, the member did not require any skilled 
services on an inpatient basis, at a SNF level of care as of July 3, 2020. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from July 3, 2020, through August 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 11, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 CPT 31797: 
 
Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), 
includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when 
performed 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does include 
documentation of removal of a foreign body; therefore, CPT 31797 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. CPT 31797 is not supported in the medical 
records. Additionally, in this case, we have confirmed that code 75710 is a column II code to column I code 
31797. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met.  Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services provided to the enrollee on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy services received from 
February 10, 2022 to March 3, 2022. 
 
You asked the Plan to waive the coinsurance for the services. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim was processed appropriately. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the services. the services falls within the Medicare Part B 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy services received 
from February 10, 2022 to March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral revision of lower eyelids provided on September 
22, 2021. 
 
You asked the Plan to pay for the bilateral revision of lower eyelids. You say that this procedure was medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage were not met for this 
procedure. 
 
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 bilateral revision of lower eyelids. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 74-year-old man with diagnoses of bilateral lower eyelid 
relative herniated orbital fat with periorbital hollows, and bilateral lower lid dermatochalasis. It is documented 
that the enrollee was entirely asymptomatic. The enrollee was fully functional with no significant limitations. 
The case file does not contain photographs. The clinical documentation does not support that bilateral revision 
of the lower eyelids was medically reasonable and necessary for the enrollee in this case.  
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 bilateral revision of lower eyelids have not been met. Therefore, we decided 
that the Plan does not have to pay for the bilateral revision of lower eyelids provided on September 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that this additional care is 
medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not 
been met. 
 
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 10 additional physical therapy visits. 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 that the additional requested therapy 
generally is not accepted as specific and effective therapy for the patients condition beyond what was 
approved by the Plan. The patient has had prior therapy and the documentation does not reveal that the patient's 
deficits require the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist.  The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient's current condition or to prevent or slow further deterioration. There has been instruction in a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter (K0801). 
 
You asked the Plan to pre-approve a motorized scooter. You say that you had a motorized scooter four months 
ago, but it broke down. You say that not having the scooter will hinder your health due to falling more often. 
The Plan denied your request. The Plan says you do not meet the criteria for a motorized scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
motorized scooter (K0801).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 00142. We decided that the Plan does not have to pay for CPT 
99100.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that these codes 
are not eligible for payment. 
 
We decided that the Plan has to pay for 00142.  
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. The definition of 
CPT 00142 is "Anesthesia for procedures on eye; lens surgery." 
 
The rules also 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 asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 00142. Our reviewer says that the medical 
records describes that the services were administered by a Certified Registered Nurse Anesthetist (CRNA). 
There were no rules found to support that a CRNA must have an anesthesiologist present during anesthesia 
services. 
 
We looked at this physician's review, the file, and Medicare rules. The plan has not substantiated their denial in 
this case. The plan has not provided a valid rationale for why a CRNA would not be an appropriate provider for 
these services. Based on this information, we decided that Medicare rules for coverage of the services have 
been met. Therefore, we decided that the Plan has to pay for 00142.  
 
We also decided that the Plan does not have to pay for 99100. 
 
The Plan follows Medicare rules. Medicare rules say that services must be reported correctly. The definition of 
CPT 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in 
addition to code for primary anesthesia procedure)." 
 
CPT 99100 has a status indicator of "B" per the physician fee schedule. This means that the code cannot be 
reported separately. Based on this information, we decided that Medicare rules for coverage of 99100 have not 
been met. Therefore, we decided that the Plan does not have to pay for 99100. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for testing services (93312) provided to the enrollee on March 11, 2022. 
 
You asked the Plan to pay for the services. You say that you are trying to bill for the interpretation of CPT 
93312, which Medicare has covered before. The Plan denied your request. The Plan says that this claim was 
billed on the same day as CPT 99222. 
 
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 93312 is "Echocardiography, transesophageal, real-time with image documentation (2D) (with or without 
M-mode recording); including probe placement, image acquisition, interpretation and report." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found there was no documentation found to 
support an evaluation and management service would not be reported with transesophageal echocardiography. 
In this case, an echo was poor quality, and a transesophageal echocardiogram was 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 services have been met. Therefore, we decided that the Plan has to pay for 
testing services (93312) provided to the enrollee on March 11, 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.