Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not necessary for 
you to be admitted into an Acute Rehabilitation Facility at this time. 
 
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 the documents does not support necessity for admission to an IRF and the complexity 
of the enrollee's nursing, and medical needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative 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 inpatient rehabilitation facility (IRF) admission and services.
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 you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested ventilator is not medically necessary. 
 
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 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and a history of 
obstructive sleep apnea and has home continuous positive airway pressure (CPAP). The enrollee has had two 
recent hospitalizations for acute respiratory failure. During the most recent hospitalization in December 2022, 
the enrollee was admitted with sepsis and pneumonia and required intubation and tracheostomy.  The enrollee was felt to have critical illness myopathy related to a previous prolonged hospitalization. 
Pulmonary function tests done as an outpatient in January confirm COPD with air trapping, and an Forced 
expiratory volume (FEV1) of 45% of predicted. The total lung capacity was normal. There is no arterial blood 
gas (ABG) done while stable to document chronic Carbon dioxide (CO2) retention. If this enrollee does have 
chronic CO2 retention, may benefit from BiPAP with average volume-assured pressure support (AVAPS) 
during sleep. This has not been tried as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. Therefore, the enrollee does not meet criteria for the requested 
device. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this is medically necessary due to deterioration of 
the spine. The Plan denied your request. The Plan says the safety and efficacy of this procedure have not been 
established. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate its safety and 
efficacy. 
 
 
  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for unresected urothelial cancer, SBRT would not be an accepted standard of care. The case record 
does not provide any literature-based, or guideline-based, recommendations to support such a treatment. It is 
unclear why SBRT is being offered as opposed to a short-course palliative regimen. The only rationale in the 
records is to provide a convenient schedule (not a medical necessity criterion) and escalate the dose (which is 
not justified with any evidence). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SBRT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for you to get back to 
baseline where you can return home with home health services. The Plan denied your request. The Plan says 
the services you need can be provided safely in another setting, such as a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Your rehab needs can be provided in a lower intensity and alternate setting such as in a skilled nursing 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the breast ultrasound provided on September 22, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were billed for a service that 
was not rendered. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing that the ultrasound was 
performed. Therefore, we decided that the Plan has to waive the copayment for the breast ultrasound provided 
on September 22, 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins 
(other than telangiectasia) (36471) stab phlebectomy of varicose veins (37765). 
 
You asked the Plan to pre-approve the vein procedure. You say that you are appealing to document the medical 
necessity of bilateral greater saphenous vein VenaSeal ablation with sclerotherapy and phlebectomy for the 
treatment of bilateral recurrent venous ulcers. The Plan denied your request. The Plan says the enrollee does 
not meet coverage guidelines set by Medicare. 
 
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 the vein procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that from a coverage criteria standpoint, the Health Plan does not provide for 
simultaneous truncal reflux treatment and tributary treatment. In order to meet conditions for approval of 
tributary treatment, there must be documentation that the truncal reflux has been addressed and that the patient 
remains symptomatic despite 6 weeks of conservative treatment following truncal reflux treatment and that the 
tributary veins to be treated are 4 millimeter or greater in diameter. A rationale for this is that appropriately 
selected patients may improve with truncal reflux treatment alone, and not require the additional tributary 
procedures. However, from a medical necessity/appropriateness standpoint, would not support any venous 
treatment on a 72-year-old former smoker with distal leg wounds without first assessing lower extremity 
arterial perfusion. The documentation does not support the medical necessity of the treatments in question.    
 
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 vein procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection of sclerosant; multiple incompetent veins (other than telangiectasia) (36471) 
stab phlebectomy of varicose veins (37765).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
August 31, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an advanced 
level (tertiary) provider. 
 
You asked the Plan to pre-approve the requested services. You say that the network provider is booked until 
September. The Plan denied your request. The Plan says you do not meet the rules for approval. 
 
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. 
 We looked at the file and the rules. The case file does not show that you have a high-risk or emergent condition 
that requires an advanced level of care. The Plan has providers at the community level who can provide the 
services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested 
services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided 
by an advanced level (tertiary) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service August 11, 
2022. 
 You asked the Plan to pay for procedure code 71045. 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 71045 is bundled into 
payment for code 36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service August 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
February 24, 2023. 
 
You asked the Plan to pre-approve SNF care after February 24, 2023. You say that the continued admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says the continued 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 after February 24, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do 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 after February 24, 2023, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after February 24, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you were admitted to the hospital in the 
beginning of January with hypercapnic respiratory failure and that she was placed on BiPAP with settings of 
IPAP 10, EPAP 5, Rate 12, FiO2 40%. The requested device would be detrimental to your health and will 
result in rehospitalization and/or death. The Plan denied your request. The Plan says the request is not 
medically necessary because your records show that the requested device is to be used in a bi-level PAP mode 
(VAPS), which can be provided by another device. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate. As stated in the Local Coverage Determination (L33800), "Claims for ventilators 
used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 
not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's care team has determined the 
home ventilator to be appropriate and necessary care. The Plan denied your request. The Plan says the records 
do not show that the enrollee has failed treatment with continuous positive airway pressure (CPAP) or bilevel 
positive airway pressure (BiPAP). 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee was treated with CPAP. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. 
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 95999. You say that train of four is integral as the benchmark in 
providing electromyography validity. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
The claim indicates code 95999 was billed for train of four testing. In this case, the MUE for CPT code 95999 
is 1. The MAI value for this code is 3. You billed 3 units of this code, exceeding the MUE. You did not provide 
all the required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Furthermore, train of four testing is bundled with the intraoperative neuromonitoring of 
electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95999 billed for date of service July 19, 2022.