Persius/hicric huggingface dataset:
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 bilevel positive airway pressure (BiPAP) is 
not adequate for respiratory support at home. The Plan denied your request. The Plan says a home mechanical 
ventilator set in intelligent volume-assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could 
be delivered by BiPAP 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 the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. You have chronic obstructive pulmonary disease (COPD) and were recently admitted to 
hospital with carbon dioxide (CO2) narcosis.  Arterial blood gasses (ABGs) were consistent with acute on chronic hypercarbic respiratory failure. You 
improved on BiPAP. You may benefit from BiPAP with AVAPS during sleep as an outpatient. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xT Solid Tumor and Hematology panel testing (81455) billed 
for date of service April 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of a physician pathology service must be the date the 
specimen was collected. The specimens in this case were collected on March 16th and March 18, 2022; 
however, the claim was billed with April 12, 2022, as the reported date of service. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be reported with 
the date of specimen collection as the date of service. However, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor argued against any of the 
exceptions to the rule applied in this case. The solid tumor specimen was collected as part of a surgical biopsy 
procedure in an outpatient hospital setting, so it is possible an exception to the general rule has been met. 
However, this possibility has not been explored or discounted by the Plan. Therefore, we decided that the Plan 
has to pay for Tempus xT Solid Tumor and Hematology panel testing (81455) billed for date of service April 
12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 76376. You say that this should be paid for. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 76376 
is a column II code to column I code 78226. 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 76376 billed for date of service May 5, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says according to the available records, the member does not meet all the required 
Medicare 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 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. The 
enrollee was admitted for a fall, Parkinson's disease and orthostatic hypotension. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for postoperative anesthesia services provided to the enrollee on 
March 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says postoperative anesthesia care is included in monitored anesthesia care, and may not be billed 
separately. 
 
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 99199 is not supported in the medical record. Specifically, it is not appropriate to report this post operative anesthesia separately in this case. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
postoperative anesthesia services provided to the enrollee on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM.) 
 
You asked the Plan to pre-approve the CGM. You say that you suffer from Parkinson's Disease with a complete 
lack of motor control. The Plan denied your request. The Plan says you do not meet the medical criteria for 
coverage of a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM.)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says the requested ventilator to deliver 
ventilatory support through settings that could be equally provided by a bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) settings is inconsistent with the criteria for 
coverage. The Plan says that a BiPAP device with AVAPS would meet all of the enrollee's needs. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator 
is not medically necessary. The enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests to confirm or assess severity. There is no arterial blood gas (ABG) done 
at baseline to document chronic carbon dioxide (CO2) retention. Therefore, the enrollee does not meet criteria 
for home ventilatory assistance. If the enrollee did have chronic CO2 retention, BiPAP would most likely meet 
the enrollee's 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 a home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network skilled nursing facility 
(SNF) provided on March 02, 2022, to March 30, 2022. 
 
You asked the Plan to waive the coinsurance for out of network skilled nursing facility (SNF). You say that if 
you would have known it would cost so much you would have gone elsewhere. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for Skilled nursing facility (SNF) care. 
 
You have been asked to pay 40% coinsurance for out of network skilled nursing facility (SNF). This 
item/service falls within the Skilled nursing facility (SNF) care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the coinsurance for out of network skilled nursing facility (SNF) provided on March 02, 2022, to 
March 30, 2022.
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 the requested device is medically necessary 
for treatment of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea/obesity 
hypoventilation syndrome. The Plan denied your request. The Plan says a home ventilator set in intelligent 
volume-assured pressure support (iVAPS) mode with auto-EPAP (AE) that could be delivered by bilevel 
positive airway pressure (BiPAP) is not a covered benefit. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. You have a diagnosis of chronic obstructive pulmonary disease (COPD), although there are no pulmonary function tests. You were recently hospitalized with acute respiratory failure, and arterial 
blood gasses (ABGs) were consistent with acute on chronic hypercarbic respiratory failure. You improved on 
BiPAP. You may benefit from BiPAP with AVAPS during sleep as an outpatient. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (92136, 66984) provided on April 8, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmology services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ophthalmology services (92136, 66984) provided 
on April 8, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on September 23, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on September 23, 
2021 by an out-of-network (OON) provider.
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 you are having issues with your ankles and you are 
unable to function without SNF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition; you don't meet all the requirements. 
 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 that from a nursing perspective, you received oral medications. You had stable vital 
signs. You were treated with IV antibiotics. Regarding rehabilitation services, you received physical therapy. 
You were at an independent level with functional mobility including gait to 300 feet. There are no identifiable 
skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled 
nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care.
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 you feel that SNF care is necessary for you. The 
Plan denied your request. The Plan says the SNF care requested 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 is a female with a history of lung and uterine cancer, stroke, and diarrhea 
due to C. difficile infection. The enrollee received oral medications and had stable vital signs. The enrollee was 
receiving physical therapy and was at a supervision to independent level with functional mobility including gait 
to 300 feet. 
 
There are no identifiable skilled nursing service needs.  There are no identifiable skilled nursing service needs; 
however, daily skilled therapy is not required. This enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged services (procedure code 99356) provided to the 
enrollee on June 21, 2021, to June 22, 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 records do not support the services 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 99356 is "Prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to 
code for inpatient or observation Evaluation and Management service)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report documents 
"additional time spent discussing patient's case with nursing staff, specialist was addition 30 minutes" Per CPT 
guidelines for CPT 99356 "Codes 99354 - 99357 are used when a physician or other qualified health care professional provides prolonged service(s) involving direct patient contact that is provided beyond the usual 
service in either the inpatient, observation or outpatient services." In this case there is a more appropriate code 
to report for service documented. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for prolonged services (procedure code 99356) provided to the enrollee on June 21, 2021, to June 
22, 2021.