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

 
We decided that the Plan has to pre-approve a non-invasive ventilator (E0466). 
 
You asked the Plan to pre-approve a NIV. You say that the enrollee's needs cannot be met with a bilevel 
positive airway pressure (BiPAP) machine. A BiPAP machine cannot provide the same pressure and flow 
ranges the enrollee needs. The Plan denied your request. The Plan says that the request for a NIV 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 NIV. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has COPD with associated 
respiratory failure that is supported in provided documentation. The enrollee would benefit from BIPAP or 
BIPAP with average volume assured pressure support (AVAPS) therapy. There is no indication of failure of 
BIPAP to necessitate home ventilation. The documentation does support the need for a ventilator as medically 
necessary. Therefore, BIPAP with or without AVAPS is reasonable therapy for this enrollee and current 
disease progression. 
 
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 NIV have been met. Therefore, we decided that the Plan has to pre-approve a 
non-invasive ventilator (E0466).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (67028) provided on May 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (67028) is included in the global 
surgery payment for the procedure (67208) provided on February 28, 2023, which has a 90-day global period. 
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 the services (67028) provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve a NIV. You say that the requested NIV is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for a NIV is not medically necessary because 
the documentation does not support that this device meets but does not exceed the enrollee's need. The records 
show that the NIV is going to be used only in a bi-level pressure mode. 
 
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 NIV. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has obesity hypoventilation 
syndrome (OHS), pulmonary hypertension (HTN), chronic kidney disease (CKD), and congestive heart failure 
(CHF) with volume overload. The enrollees documentation does support that there is chronic hypoxemic and 
hypercapnic respiratory failure. Therefore, the enrollee does meet criteria for ventilation, however, mode of 
ventilation is in question. The enrollee does not have documentation of failed or attempted bilevel positive 
airway pressure (BIPAP) and would warrant initiation with BIPAP or BIPAP with average volume assured 
pressure support (AVAPS). If failure occurs or worsening respiratory compromise, then home ventilation is the 
next best practice step. Further outpatient studies required to confirm treatment options or escalation of 
therapy. BIPAP or BIPAP with AVAPS is reasonable medical start to therapy for this enrollee. 
 
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 NIV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a non-invasive ventilator (NIV) (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that you believe that Nurtec is the appropriate treatment for 
the enrollee because of their diagnosis of migraines and risk for polypharmacy with other classes of preventive 
migraine medications. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 Nurtec.  
 
Benefits for Nurtec 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a melanoma risk stratification molecular test. 
 
You asked the Plan to pre-approve a melanoma risk stratification molecular test. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
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 melanoma risk stratification 
molecular test. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested testing is not a standard 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 a melanoma risk stratification molecular test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a melanoma risk stratification molecular test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider.  
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that your primary care doctor referred you to get checked out at this clinic as there are not 
many options available in-network. The Plan denied your request. The Plan says per the member handbook and 
benefits, in order to consider approval of an in-network request the out-of-network provider must possess 
unique skills which are required to adequately care for the member and are not available from network 
providers. This provider and/or facility does not meet this criteria based on the information provided. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 for date of service January 30, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 87798 is not payable as billed. Specifically, no medical records were provided to 
support the code billed. Based on this information, we decided that Medicare rules for coverage of procedure 
code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87798 for date of service January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service March 10, 
2023. 
 You asked the Plan to pay for procedure code 88377. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88377 is bundled into payment for code 81206. 
 
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 88377 
is a column II code to column I code 81206. 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 88377 billed for date of service March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removal of brain tumor (61510) provided on August 15, 
2022. 
 
You asked the Plan to pay for a removal of brain tumor. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a removal of brain tumor have been 
met. Specifically, medical records to support the services at issue have not been provided. Therefore, we 
decided that the Plan does not have to pay for a removal of brain tumor (61510) provided on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 22, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 glucose monitor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 glucose monitor. The Plan denied your request. The 
Plan says a continuous glucose monitor is not covered under Medicare if the enrollee is not on insulin, or does 
not have documentation of recurrent problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 glucose monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 2 glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0242U) provided on April 12, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this service 
is not covered when provided OON without a referral from the enrollee's primary care provider. 
 
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 the laboratory services (0242U) provided on April 
12, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 14, 2023, billed 
with procedure code 99222-GC. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
POS 21, as the patient was listed inpatient observation on this date of service. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on February 14, 2023, billed with procedure code 
99222-GC.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 the enrollee appears to be improving but is still somewhat unstable at this time and 
requires additional short-term acute care services that can safely be administered at the current facility until the 
enrollee is more stable and appropriate for transfer to a lower level of care soon. The enrollee does not require 
services at the LTACH that are not already available at the current facility.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Tempus Liquid Biopsy CGP Panel (81455) provided 
February 27, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered this test to help 
determine the best course of treatment for the enrollee's specific cancer and clinical presentation. The Plan 
denied your request. The Plan says the test does not have Food & Drug Administration (FDA) approval or 
clearance for this cancer and the records do not show that your cancer is recurrent, refractory, metastatic or 
advanced.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Also, the records 
do not show that your cancer is recurrent, refractory, metastatic or advanced.  Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for  the Tempus Liquid Biopsy CGP Panel (81455) provided February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you were told by hospital staff that the 
LTACH would give the enrollee the type of care they need. The Plan denied your request. The Plan says the 
criteria for admission to the LTACH have not been met. 
 
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
generalized weakness. The enrollee is not intubated/ventilated. Our reviewer found that there is no evidence 
that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to 
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Our physician 
reviewer also found that the enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from November 1, 2021, to November 5, 
2021, at the original rate code billed. 
 
You asked the Plan to pay for inpatient services at the original rate code billed. You say that these services 
were necessary and were billed appropriately. The Plan denied your request. The Plan says that the original rate 
code billed is not supported in this case. 
 
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. Specifically, the Plan indicated that records were originally provided with this 
claim, and this information was used by the Plan to change the diagnosis related group (DRG) and payment 
rate. However, no records were included in the case file forwarded to us. Without this information, we cannot 
verify that the Plan's decision was appropriate in this case. The Plan has not substantiated their denial. 
Therefore, we decided that the Plan has to pay for inpatient services provided from November 1, 2021, to 
November 5, 2021, at the original rate code billed.  
 
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 pay for the urology office visit provided on March 6, 2023. 
 
You asked the Plan to pay for the office visit. You say that your benefits cover services by an out-of-network 
provider. The Plan denied your request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
urology office visit provided on March 6, 2023.