Persius/hicric huggingface dataset:
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 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 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 
services are not medically necessary. Our physician reviewer found products classified as HCPCS code E0466, when used to provide continuous positive airway pressure (CPAP) or bi-level continuous positive airway 
pressure (PAP) (with or without backup rate) therapy, regardless of the underlying medical condition, shall not 
be paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions 
described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-
level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in the Medicare 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the KnowError genetic testing provided on May 10, 2022.  
 
You asked the Plan to pay for the KnowError genetic testing . You say that this should be paid.  The Plan 
denied your request. The Plan says this test is not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that the knowError testing is statutorily noncovered 
by Medicare.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the KnowError genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the KnowError genetic testing provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 22, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 provided on November 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) testing (93306). 
 
You asked the Plan to pre-approve TTE testing. You say that the enrollee with hypertension has a baseline 
abnormal electrocardiogram (EKG) and risk factors for coronary artery disease. The Plan denied your request. 
The Plan says the request for a routine annual echocardiogram to monitor cardiac disease is not approved. The 
records show the enrollee has no new symptoms and is medically stable from a cardiac standpoint. 
 
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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has a history of hypertension, with previous transthoracic echocardiogram (TTE). 
Documentation would not point to a change in status that would support the medical necessity of a repeat TTE 
at this time. Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or 
new signs, symptoms, or physical findings. In summary, there is no supportive evidence for the medical 
necessity of repeat TTE in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transthoracic echocardiography (TTE) testing (93306).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI of the brain. You say that the enrollee had a fall in November and 
hit their forehead, they have had a lump that has persisted since. The Plan denied your request. The Plan says 
that they have not received the notes form they CT scan that was approved on April 20, 2023.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI of the brain. Our reviewer says 
that the MRI is medically necessary. Our physician reviewer found in the letter of appeal that the physician had 
originally ordered a computed tomography (CT) scan of the brain but received a denial letter from the plan 
stating that MRI is the procedure of choice. Therefore, there are no results of a CT scan. The recommended 
MRI as stated by the plan is reasonable and should be approved. 
 
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 MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say you cannot do your daily activities, have difficulty walking and are at risk for 
falling. You say you need inpatient therapy. The Plan denied your request. The Plan says that the request for an 
IRF admission is not supported based on the records received.  
 
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. We find that no records were identified for IRE review. Per the Plans summary, 
records were received from the provider and reviewed for multiple dates. The Plan has failed to support its 
denial. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.  
 
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: 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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF admission you requested 
is not supported based on the records received.  
 
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 the intensity of services provided at an IRF. Specifically, you ae 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says there has not been a reasonable trial of conservative management and 
there are documented bilateral sacral insufficiency fractures. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is covered for fractures that 
have not responded to non-surgical medical management. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found there is no documentation of a 
trial of bracing. More conservative measures are 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty.
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 has complex medical conditions that 
require inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee can safely receive the 
services they need 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 the enrollee does 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. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the clinical information provided supports the need for 
Botox injections.  The Plan denied your request. The Plan says that the medical necessity guidelines for 
coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Botulinum toxin injection therapy is accepted first line 
treatment for patients with blepharospasm and/or hemifacial spasm. 
 
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 Botox. Our reviewer says that the 
criteria for coverage have been met.  Our physician reviewer found the enrollee has right sided hemifacial 
spasms that are causing disruption. This is an indication that allows for Botulinum toxin injections as a first line 
treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve radiation oncology services. You say that you are appealing this denial. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can be 
treated within the Plan network. 
 
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 
radiation oncology services 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 pay for the pneumatic compression device provided on May 18, 
2022, to June 8, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
equipment used in a facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 18, 2022, to June 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
medical necessity criteria for a SNF admission.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, the 
intermittent skilled services can be provided at a lower level of care than 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the continued admission to a SNF is not medically necessary after 5/27/23. 
 
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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device (E0935) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CPM device. You say that you disagree with the denial. The requested 
CPM device is not available with an in-network provider. The Plan denied your request. The Plan says there 
are participating DME providers with rentable CPM devices available in network. 
 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 
a continuous passive motion (CPM) device (E0935) to be provided 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 this is medically necessary. The Plan denied your 
request. The Plan says a SNF admission 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 that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing or skilled therapy needs. The enrollee is consistently ambulating more than 100 
feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs are 
custodial and can, as a practical matter, be provided at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the know error DNA Specimen Provenance Assay billed 
with codes 81266 and 81265 for date of service June 16, 2022. 
 
You asked the Plan to pay for codes 81266 and 81265. You say that you have provided the lab report in support 
of payment for this claim. The Plan denied your request. The Plan says this testing is not covered. The Plan 
must follow Medicare rules. Medicare rules say that the know error DNA Specimen Provenance Assay is a 
statutorily excluded test. Therefore, we decided that the Plan does not have to pay for the know error DNA 
Specimen Provenance Assay billed with codes 81266 and 81265 for date of service June 16, 2022.