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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
continued SNF services. You say the enrollee has not been given a fair amount of time to start and progress 
through their physical rehabilitation plan. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for continued skilled nursing services. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed for date of service 
October 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed in accordance with policy. 
The Plan denied your request. The Plan says the proof of delivery is not valid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the electrical 
stimulator supplies billed for date of service October 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you need to get to your medical 
appointments. The Plan denied your request. The Plan says routine transportation is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a replacement of an aortic valve with zoo plastic tissue, 
Percutaneous approach (02RF38Z), provided on May 10, 2022, through May 13, 2022. 
 
You asked the Plan to pay for the replacement of the aortic valve. You say that the services were medically 
necessary. The Plan denied your request. The Plan says a clinical trial procedure was billed without its 
mandatory clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that the clinical trial number must be reported on 
claims involving clinical trials. 
 An appropriate clinical trial number was not reported for this claim. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement of the aortic valve. have not been met. Therefore, we decided that the Plan does 
not have to pay for a replacement of an aortic valve with zoo plastic tissue, Percutaneous approach (02RF38Z), 
provided on May 10, 2022, through May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion, any size 
(E2609) and a custom fabricated wheelchair back cushion, any size, including any type mounting hardware 
(E2617). 
 You asked the Plan to pre-approve customized seat cushions. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the requested items are not deemed medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve customized seat cushions. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are non-ambulatory and require a manual wheelchair for mobility and 
performing your basic daily activities. You require tilt in space manual wheelchair given that you cannot 
independently perform pressure relief and have a gluteal pressure wound. A prefabricated seat and back 
cushion should be sufficient to meet your seating needs in terms of pressure relief. You do not have a 
significant orthopedic or neurological condition that would necessitate more complex seating. Therefore, the 
custom fabricated wheelchair seat cushion (E2609) and back cushion (E2617) are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of customized seat cushions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom fabricated wheelchair seat cushion, any size (E2609) and a custom 
fabricated wheelchair back cushion, any size, including any type mounting hardware (E2617).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 7, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 7, 
2022.
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 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 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
30, 2022. 
 You asked the Plan to pay for procedure code 76641. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation supplies billed for date of service 
October 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed in accordance to guidelines. 
The Plan denied your request. The Plan says the proof of delivery is not valid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain valid proof of delivery for the supplies provided in this case. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the electric stimulation supplies billed for date of service October 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation may be covered for the relief 
of chronic intractable pain under specific circumstances as listed above. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet any of the required indications. Our physician reviewer found there is no 
surgical consultation and the efficacy of SCS in spinal stenosis has reportedly been very poor. The enrollee 
does not have an evidence-based indication for this procedure. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on December 12, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the tests are covered by Medicare. The Plan 
denied your request. The Plan says the testing does not meet the standard of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
enrollee was symptomatic and at high risk for UTI complications. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the urinary tract infection panel provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have back pain. The record provided does not document the presence of a 
subluxation of the spine demonstrated by either physical examination or imaging studies. The elements of the 
coverage criteria are not satisfied. The requested services are not recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 06, 2021, 
through August 09, 2021, and billed with diagnosis code A41.4. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.4 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.4-Sepsis due to anaerobes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.4-Sepsis due to 
anaerobes. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
A41.4-Sepsis due to anaerobes. Our physician reviewer found the member was alert and oriented. The 
member's vital signs showed a temperature of 98.4, heart rate of 108, blood pressure of 141/63, respiratory rate 
of 18, and Oxygen saturation at 95% on room air. The member's blood cultures were positive for Bacteroides 
fragilis. Chest x-ray was negative, and computerized tomography (CT) scan of the abdomen/ pelvis showed 
mild cardiomegaly, mild interlobar septal thickening in the lungs, patchy ground glass opacification and 
nodular opacities and mild colonic diverticulosis. Patient was treated with IVF and intravenous ceftriaxone 
antibiotics. There was no clinical or laboratory evidence of sepsis, therefore, diagnosis code A41.4-Sepsis due 
to anaerobes is not the appropriate primary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 06, 2021, through August 09, 2021, and billed with 
diagnosis code A41.4.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on January 27, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for inpatient hospital care provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital care provided have 
been met. Specifically, you did not provide medical records for the dates of service at issue. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided on January 27, 2022, to February 
5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary to avoid a stroke. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that a 
portable oxygen concentrator is considered not medically necessary because Medicare criteria are not met. You 
have dyspnea and cough, and hypoxemia.  It is unclear from the record whether you currently have 
supplemental oxygen at home. One note indicates that you are using your wife's oxygen at nihht. There is no 
documentation that the SpO2 can be maintained greater than 91% during activity on oxygen at 1 to 4 L/min 
using an oxygen conserving device. There is no documentation that a standard concentrator and portable 
oxygen system would not meet your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) (84443) and 
thyroxine; free (84439) provided on September 2, 2022.  
You asked the Plan to pay for the TSH testing and assay of free thyroxine. You say that this test was medically 
necessary. The Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the TSH testing and assay of free thyroxine, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the thyroid stimulating hormone (TSH) (84443) and thyroxine; free (84439) provided 
on September 2, 2022.