Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 00142. We decided that the Plan does not have to pay for 99100.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the claim is 
missing a modifier. 
 
We decided that the Plan has to pay for 00142.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT code manual definition of 
CPT 00142 is "Anesthesia for procedures on eye; lens surgery." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 00142 Our reviewer says that the provider 
report CPT 00142 with modifiers QY, P3, QS, and 22, per the provider remittance and health insurance claim 
form. Th procedure report describes a certified registered nurse assistant (CRNA) performing the anesthesia 
services, and anesthesiologist was present during the procedure. In this case, QY - direction of one certified 
registered nurse anesthetist by an anesthesiologist - was appropriate. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
00142.  
 
We also decided that the Plan does not have to pay for 99100. 
 
The Plan 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 CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of this code have not been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 99100. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Eliquis.  
 
 Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says a home mechanical ventilator set in iVAPS mode with Auto-EPAP (AE) 
could be delivered by a BiPAP, so this item is not covered. 
 
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 this patient has a diagnosis of 
chronic obstructive pulmonary disease, severe pulmonary hypertension, and presumed obstructive sleep 
apnea.  The patient has BiPAP at home but has not been using it. The device is broken according to the son. 
The patient was recently hospitalized with a urinary tract infection and sepsis, and the ventilator was ordered at or after discharge. There are no pulmonary function tests to confirm the diagnosis of chronic obstructive 
pulmonary disease and assess severity. Chronic sedative and narcotic use are likely contributing to chronic 
hypoventilation. This patient may benefit from regular use of BiPAP during sleep, which can provide the 
AVAPS mode.  There is no evidence of failure of bipap in the home 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic socket with vacuum socket system, the 
alignable system and other parts. 
 
You asked the Plan to pre-approve prosthetic socket with vacuum socket system, the alignable system and 
other parts. 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 follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 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 prosthetic socket with vacuum socket 
system, the alignable system and other parts. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found the documentation support a socket replacement for you in this case. However, 
there is insufficient evidence at this time to support any particular suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic socket with vacuum socket system, the alignable system and other 
parts have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic socket 
with vacuum socket system, the alignable system and other parts.
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 necessary for this patient. 
The Plan denied your request. The Plan says the patient does require daily physical, occupational or speech 
therapy five days per week as they are able to move around in bed without much assistance and are able to 
transfer from bed to chair and walk with a walker for 40 feet with one person having a hand to assist as needed. 
In addition, the patient does not require daily skilled nursing services such as daily wound care or intravenous 
(by vein) medications. The patient's needs can be met at an alternate lower level of care.  
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 SNF 
care is not medically necessary. Our physician reviewer found the patient has documented skilled nursing and 
skilled therapy needs but evaluating therapists document that the patient would be able to safely receive skilled 
therapy services at home and there is no documentation to show that patient's skilled nursing needs must be 
daily or on an inpatient basis 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 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 pay for inpatient hospital services provided to the enrollee from 
August 15, 2021, to August 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the determination to remove the secondary diagnosis was appropriate.  
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 DRG 199 (PNEUMOTHORAX WITH MCC). 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
review has determined that the records did not support that J96.21 - acute on chronic respiratory failure with 
hypoxia - as a valid diagnosis in this case. The appropriate DRG is DRG 200: PNEUMOTHORAX WITH CC.  
 
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 to the enrollee from August 15, 2021, to August 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 94060, 94726, and 94729 billed for date of service 
March 14, 2022. 
 
You asked the Plan to pay for procedure codes 94060, 94726, and 94729. You say that you have provided 
records to support payment. The Plan denied your request. The Plan says that the records do not support the 
necessity of these services. 
 
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 procedure codes 94060, 94726, and 94729. 
Our reviewer says that procedure codes 94060, 94726, and 94729 are considered medically reasonable and 
necessary in this case. Our physician reviewer found full pulmonary function testing, including spirometry, 
bronchodilator challenge, lung volumes via plethysmography, and diffusing capacity are reasonable and 
medically necessary in the investigation of dyspnea of unknown etiology.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 94060, 94726, and 94729 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 94060, 94726, and 94729 billed for date of service March 
14, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that daily physical and occupational therapy is not medically necessary. Your 
needs can be met with intermittent physical and occupational three to four times per week. Your needs are 
largely custodial at this time. Medicare guidelines state that custodial care services are not covered. Further 
daily therapies are not reasonable or necessary for the treatment of an illness or injury and are not necessary to 
establish a safe and effective maintenance program or to prevent your condition from getting worse. The 
criteria for the requested skilled nursing admission has not been met. Your care needs can be provided in a 
lower level of care setting, such as with home health 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 SNF 
care is medically necessary for you. Our physician reviewer found the clinical documentation shows that you 
have new cognitive and mobility deficits related to a brain injury thus would require close monitoring by a 
skilled nurse on a daily basis with acute neurobehavioral impairments. Both physician and evaluating therapists 
recommend skilled therapy in a skilled nursing facility and you have documented mobility and self care 
impairments. From a practical matter, the clinical documentation shows that daily skilled nursing and therapy 
services on an inpatient basis in a skilled nursing facility are medical 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile gloves provided for the enrollee on December 19, 
2021. 
 
You asked the Plan to pay for the gloves. You say that this should be paid for. The Plan denied your request. 
The Plan says this charge is not a reasonable allowable expense, because it is a separately billed professional 
component for a lab service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A4930 is "Gloves, sterile, per pair." 
 
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 gloves. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the documentation does not support 
the reporting of gloves separately from laboratory or emergency department services provided. Gloves are 
typically used when providing laboratory services or other care and would be included in the procedure the 
gloves are being worn for.  
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 gloves have not been met. Therefore, we decided that the Plan does not have 
to pay for sterile gloves provided for the enrollee on December 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are requesting to see your original primary 
care physician (PCP) who is no longer in-network with the Plan. You also say you have tried to see a couple of 
other PCP's, and you did not have a good experience with them. You would like reconsideration to continue to 
see your PCP. The Plan denied your request. The Plan says you must use network providers to get your medical 
care and 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 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 
an office visit to be provided 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 shower chair with arms (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you need the shower chair because you are 
unable to stand while taking a shower. The Plan denied your request. The Plan says a bath/shower chair is 
considered hygienic equipment and not medically related, therefore, it is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair with arms (E0240).
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 necessary. The Plan denied 
your request. The Plan says you have not had a change in function warranting daily skilled therapy; therefore, 
there is no need for daily skilled therapy services to be provided by a skilled therapist on a daily basis and there 
are no daily skilled nursing needs. It is therefore feasible to meet your needs at a lower level of care, 
 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 SNF 
care is not medically necessary. Our physician reviewer found you have no identifiable skilled nursing needs.  
While you do have skilled therapy needs, you do not require skilled therapy on a daily basis in an inpatient 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and miscellaneous, durable medical 
equipment (E1399). 
 
You asked the Plan to pre-approve a combination sit-to-stand frame/table system and miscellaneous DME. You 
say that you have an illness and need this DME immediately. The Plan denied your request. The Plan says 
Medicare guidelines specifically classify standing tables as convenience items and not primarily medical in 
nature. The requested miscellaneous item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and miscellaneous, durable medical 
equipment (E1399).
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 necessary. The Plan denied 
your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy 
in a SNF setting. You have not had physical therapy or a recent assessment since March of 2022. 
 
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 SNF 
care is not medically necessary. Our physician reviewer found you have skilled nursing needs such as ostomy 
care and close monitoring of skin for prevention of breakdown but there is no documentation that would 
support the need for this care on a daily basis. You were documented as being bed bound and require assistance 
but there is no documentation to show that you require the assistance of a skilled therapist on a daily basis.  
 
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.