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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD), with forced expiratory volume 
(FEV1) reportedly 21% predicted. However, there is no documentation of chronic carbon dioxide (CO2) 
retention with an arterial blood gas (ABG) done while stable. If the enrollee does have chronic CO2 retention, 
may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON office visits. The Plan denied your request. The Plan says these 
services can be provided in-network. 
 
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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been 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 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 that the enrollee does not require skilled nursing services with the specialized skill, 
knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. There is no documentation of new enteral feedings, complex wound care or 
other SNF nursing need. The enrollees 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 only in a SNF. The enrollee does not require skilled nursing or skilled 
therapy on a daily basis or as a practical matter 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF and their 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies 15 hours a week under the supervision of a physician. 
The enrollee can receive further services at a lower level of care. 
 
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 continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items. 
 
 
 
 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 related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that you have 
difficulty with finger pricks due to your vision and hand mobility. The Plan denied your request. The Plan says 
the requirements for coverage have not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM).
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. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria 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 that the enrollee's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and  
 occupational therapy, the documentation does not reveal that the enrollee requires this therapy on an intensive 
IRF level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing coded as 87798, 87481, 87491, 
87591, 87640, 87651, 87653 and 87661. 
 
You asked the Plan to pay for the laboratory service. You say that all services rendered were properly ordered 
and signed by the referring physician and deemed medically necessary for this enrollee per diagnosis of 
treatment. The Plan denied your request. The Plan says PCR testing is considered unproven and not medically 
necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine PCR panel testing coded as 87798, 87481, 87491, 87591, 87640, 87651, 87653 and 87661.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy (PT) services (97750, 97535, 
97162, 97110) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that you offer the best physical therapy for the 
enrollee and feel you should be covered as in-network. The Plan denied your request. The Plan says this service 
is not covered OON. 
 
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 
the physical therapy (PT) services (97750, 97535, 97162, 97110) to be provided by an out-of-network (OON) 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from June 13, 2022, 
to July 5, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment because the RAP was not submitted late. The Plan denied your request. The Plan says 
the deadline for submission of the home health claims NOA was within 5 days of the start of care. The Plan 
also says that the NOA was not submitted until July 12, 2022, for the home health care period which started on 
June 13, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit an NOA to their Medicare 
contractor within 5 calendar days after the start of care date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the NOA was 
not submitted within 5 calendar days from the start of care date. Therefore, we decided that the Plan does not 
have to pay for the home health care services provided from June 13, 2022, to July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Emsella chair for pelvic floor rehabilitation. 
 
You asked the Plan to pre-approve the Emsella chair. You say that you are appealing the approval for electric 
chair treatment for your incontinence. The Plan denied your request. The Plan says the Emsella chair used for 
pelvic floor rehabilitation is not listed as a covered service by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Emsella chair have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Emsella chair for pelvic floor rehabilitation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 7, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the record does not 
include documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as 
required by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 15, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88360, and 88381 have a Professional/Technical indicator of 1. This 
means that CPT codes 88341, 88342, 88360, and 88381 have both a professional and technical component. In 
this case, CPT codes 88341, 88342, 88360, and 88381 have not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service February 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized with COVID-19 and hypercarbic respiratory failure. 
However, no arterial blood gas (ABG) data are provided in the medical record. There is no documentation of 
chronic carbon dioxide (CO2) retention with ABG while stable. There is no evidence that bilevel positive 
airway pressure (BiPAP), with or without average volume-assured pressure support (AVAPS), was tried and failed as an outpatient. There is a listed diagnosis of chronic obstructive pulmonary disease (COPD), but 
pulmonary function testing in 2021 was restrictive disease, probably moderate in severity; forced expiratory 
volume (FEV1) is not provided. Therefore, a diagnosis of COPD is not supported. There is a diagnosis of 
thoracic restrictive disease due to kyphoscoliosis. However, it does not appear to be severe enough, by itself, to 
cause chronic CO2 retention. There is no diagnosis of neuromuscular disease. If this enrollee does have chronic 
CO2 retention, may benefit from BiPAP during sleep. But 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), blood draw (36415), and complete 
blood count (85025) provided on April 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the routine services received out-of-network are not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204), blood draw (36415), and complete blood count 
(85025) provided on April 23, 2022, 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 Dexcom G6 receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that the records provided support the need 
for the requested device. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 you do not use insulin with at least three daily injections. Specifically, you are only using Novolin 40u in the morning and after dinner each day. 
Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 receiver have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3002) and orthopedic shoes (L3221). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of these 
items for your condition. Additionally, Medicare rules say that with the exception of the situations described 
above, orthopedic footwear billed using codes L3002 and L3221 will be denied as non-covered. Therefore, we 
decided that the Plan does not have to pre-approve foot orthotics (L3002) and orthopedic shoes (L3221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64635 and 64636). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this is a request for ablation at three levels which is more than medical policy allows. 
 
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 services. Our physician reviewer 
found facet joint injections are indicated for:  No more than 1 to 2 levels, either unilateral or bilateral, per spine 
region is injected per session. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare 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 services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent 
(64635 and 64636).