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

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item 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 home mechanical ventilator. Our 
reviewer says that the member does not need this item Our physician reviewer found this patient has a 
diagnosis of COPD with repeated hospitalizations, but there are no pulmonary function tests to confirm and 
assess severity. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. If the patient has 
severe COPD and chronic CO2 retention, may benefit from BiPAP with AVAPS. Medicare does not cover a 
home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the LTACH setting is necessary to perform 
the necessary care and management of the enrollee's multiple medical complexities. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you went 
into atrial fibrillation and had to call the emergency medical services to be checked out, but by the time they 
arrived you were better and did not want to go to the emergency room. You also say that you cannot afford to 
pay $200 every time you have an emergency. The Plan denied your request. The Plan says this service is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport provided on March 6, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that it is 
generally the ordering facility's responsibility to obtain the proper authorization. The Plan denied your request. 
The Plan says the request authorization is not on file. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport. Our reviewer says that the service is not medically necessary.  
 Our physician reviewer found the record indicates that the enrollee was transported from an acute care hospital 
to a psychiatric in-patient facility via stretcher in a semi-upright position. The record does not indicate that the 
enrollee's clinical condition is such that other methods of transport, such as stretcher van, are contraindicated or 
that the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance 
can provide was required. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. 
 
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 ambulance service, basic life support, emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, 
emergency transport provided on March 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an 
LTACH to regain a maximum level of functioning and continue multidisciplinary approach to care. You say 
that the enrollee needs more recovery time to safely allow them to return to their previous home setting. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 while the enrollee may need 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 this 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 pre-approve Signatera lab testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that minimal residual disease testing is only covered 
under certain medical indications.  
 
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 requested testing. Our physician 
reviewer found that the enrollee has appendiceal cancer. Recent imaging raises questions of metastasis. 
Signatera is a highly sensitive and personalized molecular residual disease assay (MRD) using circulating 
tumor DNA (ctDNA), custom designed for each patient to help identify relapse earlier than standard of care 
tools. As imaging shows recurrence, the requested test is 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 the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Signatera lab testing.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 5, 2022, to 
May 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was filed timely. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked the file and the Medicare rules. We find that the claim at issue was not billed with an admission 
date in 2022 that matches a valid NOA on file. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from April 5, 2022, to May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device placement procedure (22869 and 
22870). 
 
You asked the Plan to pre-approve a Vertiflex device placement procedure. You say that the services are 
medically necessary. The Plan denied your request. The Plan says these services are considered experimental. 
 
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 device placement procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found these services are considered experimental and more research is needed in 
order to show 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 device placement procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex device placement procedure (22869 and 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis of breast tumor tissue, profiling of 70 
content genes and 465 housekeeping genes (81521) provided on September 7, 2022. 
 
You asked the Plan to pay for the gene analysis of breast tumor tissue. You say that this code should be 
covered. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81521 is unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as not medically 
necessary. 
 
We looked at the file and Medicare rules. This code is not covered under Medicare. Based on this information, 
we decided that Medicare rules for coverage of the gene analysis of breast tumor tissue have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene analysis of breast tumor tissue, profiling 
of 70 content genes and 465 housekeeping genes (81521) provided on September 7, 2022.
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 enrollee's needs cannot be met at a lower level of 
care. The Plan denied your request. The Plan says based on Medicare guidelines, the request for IRF services 
does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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 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 power wheelchair, group 2 standard, captain's chair, 
patient weight capacity up to and including 300 pounds (K0823), a power wheelchair accessory, 22 NF sealed 
lead acid battery (E2361), a manual swingaway, retractable or removable mounting hardware for joystick 
(E1028) and a wheelchair accessory, adjustable height, detachable armrest, complete assembly (E0973). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is unable to 
utilize a cane or walker secondary to severe gait instability, frequent of falls and LE weakness. He is unable to 
utilize a manual wheelchair secondary to chronic shoulder pain, upper extremity weakness and deconditioning. 
The Plan denied your request. The Plan says there is no evidence provided showing the swingaway mounting 
hardware for the joystick needs to be moved to transfer the enrollee. This request is denied as not medically 
necessary. The PWC does not meet criteria and therefore all of the above accessories are denied as well. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
hemiparesis from a stroke, impaired ambulation and repeated falls. He also has dementia. The record provides 
no objective measurements of his upper body strength or evidence the enrollee is able to safely operate a 
powered mobility 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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captain's chair, patient weight 
capacity up to and including 300 pounds (K0823), a power wheelchair accessory, 22 NF sealed lead acid 
battery (E2361), a manual swingaway, retractable or removable mounting hardware for joystick (E1028) and a 
wheelchair accessory, adjustable height, detachable armrest, complete assembly (E0973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94060 provided on March 31, 2022. 
 
You asked the Plan to pay for procedure code 94060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code billed. 
 
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 94060 is Bronchodilation responsiveness, spirometry. 
 
We find that CPT code 94060 is not supported in the medical record. Specifically, the medical records provided 
do not describe the code billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 94060 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94060 provided on March 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on August 18, 2022. 
 
You asked the Plan to pay for drug testing. You say that you conducted the testing ordered by the referring 
physician in good faith. The Plan denied your request. The Plan says that this provider is out-of-network with 
the Plan and authorization was not obtained. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
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 specify whether the ordering physician was in-network or out-
of-network with the Plan. The record does not include prior notice from the Plan that this testing would not be 
covered. Without this information, we cannot determine whether the lab order made constituted plan-directed 
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided on 
August 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate denture, mandibular (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that you are in need of the implant as your 
partial denture moves a lot and it is almost impossible to chew. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an immediate denture, mandibular (D5140).