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

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a bilevel positive airway pressure (BiPAP) device 
does not have a tidal volume setting. The Plan denied your request. The Plan says a ventilator is not covered by 
Medicare for the requested purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 admission to an IRF is not medically necessary. 
 
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 does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) billed with the CS modifier for date of 
service April 18, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service is supported as billed. The Plan denied 
your request. The Plan says modifier CS billed with this service is not appropriate or supported in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that modifier CS is not supported in the medical record. Specifically, it is unclear how this drug testing 
relates to the current Public Health Emergency. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing (G0482) billed with the CS modifier for date of service April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure (LAAC) 
procedure. 
 
You asked the Plan to pre-approve the LAAC procedure. You say that it is felt that this procedure should be 
allowed as the enrollee does not wish to remain on blood thinners for the rest of life. The Plan denied your 
request. The Plan says the enrollee has no medical reasons that long-term anticoagulation cannot be continued. 
As such, this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC treatment is only covered for enrollees that are 
not able to take long-term anticoagulation.  
 
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 LAAC procedure. Our reviewer 
says that the records do not support that the coverage criteria for the LAAC procedure are met. Our physician 
reviewer found the records reveal that there is no apparent contraindication to anticoagulation. As such, 
guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not 
be considered reasonable or medically necessary in this patients 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 the LAAC procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous left atrial appendage closure (LAAC) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with a single power 
option (power tilt seating system). 
 
You asked the Plan to pre-approve the Group 2 PWC with power tilt. You say that it is felt that the requested 
PWC is medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for this 
specific PWC are not met. It is noted that the criteria for a Group 2 PWC with no power options may be met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested PWC with a single power option may 
be covered when the enrollee meets criteria for a power tilt or recline seating system. 
 
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 Group 2 PWC with power tilt. Our 
reviewer says that the documentation does not support that the criteria for a power tilt seating system are met. 
Our physician reviewer found the medical records submitted do not reveal that the enrollee is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. Since the power tilt seating system does not meet 
criteria, the requested PWC base cannot be approved. 
 
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 Group 2 PWC with power tilt have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with a single power option (power 
tilt seating system).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on May 22, 2020, 
through July 14, 2020 and denied by the Plan with codes G, B and C. 
 
You asked the Plan to pay for the inpatient hospital services. 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 services billed. 
 
The Plan follows Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge 
 
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 inpatient hospital services. Our reviewer says that the itemized bill items denied with code G do not meet criteria for payment or reimbursement consideration. The 
healthcare provider is reporting daily hospital care; subsequent hospital care; advanced care planning; glucose 
monitoring; supplies; inpatient consult and prolonged service.  The documentation does not support these 
services are separate from the routine services for inpatient hospital stay. The itemized bill items denied with 
code B do not meet criteria for payment consideration. The medical record includes insufficient documentation 
to confirm that these services billed separately.  Nursing notes for medication administration and supplies used 
were not found. Therefore; these services cannot be verified. 
 Our reviewer found the itemized bill items denied with code C do not meet criteria for payment consideration. 
The medical record includes radiology services and physician care.  No physician orders for hospital services 
were not found in documentation and therefore cannot be verified 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided on May 22, 2020, through July 14, 2020 
and denied by the Plan with codes G, B and C.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXBladder Detect test (0012M) provided on February 
25, 2022. 
 
You asked the Plan to pay for the CXBladder Detect test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXBladder Detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXBladder Detect test (0012M) provided on February 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 19, 2022, to 
January 20, 2022. 
 
You asked the Plan to pay for physician's services. You say that you are billing within CMS guidelines. The 
Plan denied your request. The Plan says services from non-participating providers are not covered under an 
HMO plan unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 physician's services provided from January 19, 2022, to 
January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from May 13, 2022, to 
June 24, 2022. 
 
You asked the Plan to pay for physician's services. You say that you did not know that you are not contracted 
with this Plan. The Plan denied your request. The Plan says it is the responsibility of the provider to verify 
coverage/benefits prior to rendering services. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 physician's services provided from May 13, 2022, to  
June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 4, 
2022, to May 3, 2022. 
 
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 admit date was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 home health services provided to the enrollee from April 4, 2022, to May 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 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, we have confirmed that code 99283 
is a column II code to column I code 99284. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service July 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venlafaxine. 
 
You asked the Plan to pre-approve Venlafaxine. You say that the medication is necessary. The Plan denied 
your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Venlafaxine.  
 
Benefits for Venlafaxine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service July 1, 2022. You asked the Plan to pay for procedure code 97110. You say that this service was reported correctly. The Plan 
denied your request. The Plan says this service was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that only lines with revenue code 
42x may be reported with/contain modifier GP. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, this service was reported 
with modifier GP but was reported with a 41x revenue code rather than a 42x revenue code. Based on this 
information, we decided that Medicare rules for coverage of procedure code 97110 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97110 billed for date of service 
July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the services were medically necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 4, 2022 to March 
5, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date on the NOA is January 5, 2022. The admit date on the claim does not match. 
(June 9, 2021). Therefore, we decided that the Plan does not have to pay for home health services provided on 
February 4, 2022 to March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Freestyle Libre 2 continuous glucose monitor (CGM) 
supplies rendered on October 9, 2021. 
 
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 exceed the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that billing more than one (1) unite of service per thirty 
(30) days of code K0553 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that code K0553 was billed for more than one UOS 
per 30 days. 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 pay for the Freestyle Libre 2 continuous glucose 
monitor (CGM) supplies rendered on October 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that services are medically necessary. 
The Plan denied your request. The Plan says that the information provided does not show that the enrollee 
needs full inpatient status for care. Vital signs were stable. Enrollee did not have any immediately dangerous 
lab findings or require any advanced treatments. An observation level of care would have been appropriate. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient hospital care is met in this case. Our 
physician reviewer found the enrollee presented to the emergency department on 12/12/22 with fever and 
cough. She was evaluated and found to have pneumonia. She was treated with IV antibiotics and continued 
with HD. The review has determined that the record showed 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 pre-approve acute inpatient hospital care.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided on July 11, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the provided documentation does not clearly show that the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 F1CDx testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the computed tomography (CT) scan shows multiple pulmonary nodules. The imaging to 
confirm metastatic adenocarcinoma lung. This testing is reasonable and necessary for stage IV non-small cell 
lung cancer.  
 
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 F1CDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx (F1CDx) testing (0037U) provided on July 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.