Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96366 rendered on December 28, 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 Current Procedural Terminology (CPT) code 96366-59 (2 units) remains 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. 
 
In this case, the CPT Code Manual definition of code 96366 is "Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure)." 
 
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 medical record submitted for review includes a "Progressive Infusion Flow Sheet;" however, the medication and dosage for infusion is not 
included in the report, and therefore the procedure code and units cannot be verified. 
 
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 procedure code 96366 rendered on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that the enrollee cannot leave the hospital without the 
NIV approved.  The Plan denied your request. The Plan says the enrollee's needs can be met with a lower level 
device. 
 
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 the NIV. Our reviewer says that the NIV is not shown to be reasonable and necessary in this case.  Our physician reviewer found the enrollee has 
COPD and was hospitalized in July with an exacerbation.  Arterial blood gases (ABG) were consistent with 
acute on chronic hypercarbic respiratory failure. The enrollee improved clinically on bilevel positive airway 
pressure (BiPAP). There are no pulmonary function tests to assess the severity of the COPD. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. There is no ABG done while stable to 
document chronic carbon dioxide retention. If that is present, the enrollee may benefit from BiPAP with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. There is no documentation 
that this has been tried and shown to fail as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with 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 the NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a chest x-ray provided on February 21, 
2023.  
 You asked the Plan to pay for the x-ray interpretation. You say that this was coded correctly and should be 
paid.  The Plan denied your request. The Plan says this is not covered for screening purposes.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
In this case, the chest x-ray was billed solely with diagnosis Z87.891, personal history of nicotine dependence. 
No other signs/symptoms of disease were documented. As such, this is considered to be a screening procedure 
and is not among those covered by Medicare.  Therefore, we decided that the Plan does not have to pay for the 
interpretation of a chest x-ray provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute (Q4187). 
 
You asked the Plan to pre-approve the services. You say that this is a necessity for your care. The Plan denied 
your request. The Plan says this is 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation supports that this enrollee is suffering with an ulceration to the plantar 
lateral aspect of the right heel. During the most recent visit dated 7/25/23, it is noted that the wound measures 
0.3 cm x 0.2 cm x 0.7 cm. This is noted to be dramatically reduced in size as compared to the prior visit dated 
6/13/23 in which the ulceration measures 0.8 cm x 0.4 cm x 1 cm. In this particular case the ulceration is noted to have reduced in size drastically between the last to office visits. The enrollee is noted to be offloading the 
area with a CAM boot, receiving serial debridement, and applying dressings daily. It is unclear as to why a skin 
substitute is required, when the ulceration is resolving with the above-mentioned conservative treatments. At 
this point, it seems that a skin substitute would exceed the enrollees medical 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute (Q4187).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(99239) provided on November 12, 2022. 
 
You asked the Plan to pay for discharge management. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the documentation does not support the service 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
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 discharge management. Our reviewer says that the service is not supported. Our reviewer found documentation does not include documentation of time spent on the 
procedure performed, and therefore cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of discharge management have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital discharge day management; more than 30 minutes (99239) provided on 
November 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a neurostimulator (64590). 
 
You asked the Plan to pre-approve placement of a neurostimulator. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met.  
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 placement of a neurostimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the neurostimulator (64590) at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not 
document the enrollee is refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and is an appropriate surgical candidate such that implantation with anesthesia can 
occur. There is no documentation indicating that stress incontinence, urinary obstruction, and specific 
neurologic diseases (e.g., diabetes with peripheral nerve involvement) have been excluded. Records do not 
document a successful test stimulation in order to support subsequent implantation or a 50% or greater 
improvement through test stimulation measured through voiding diaries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve placement of a neurostimulator (64590).
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 an IRF admission will reduce future risk for you and 
accelerate the time frame for returning home. The Plan denied your request. The Plan says your records do not 
show you need an intensive team (rehabilitation doctor and nurse, social worker, and therapists) for your care.  
 
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 your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of cholecystitis. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do 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 you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV).  
 
You asked the Plan to pre-approve the NIV. You say that it is felt this is necessary. The Plan denied your 
request. The Plan says criteria for NIV are not 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 the NIV. Our reviewer says that the 
NIV is not medically necessary.  Our physician reviewer found the enrollee has severe obesity, obesity hypoventilation syndrome, and obstructive sleep apnea. He was readmitted to the hospital on July 12, 2023, for 
pneumonia and is described in the hospital note as intolerant of continuous positive airway pressure 
(CPAP).  Arterial blood gas (ABG) showed mild compensated hypercapnia, but there is no ABG done while 
stable to document chronic carbon dioxide retention. If that is present, the patient may benefit from bilevel PAP 
(BiPAP) during sleep as an outpatient, if compliance can be achieved. The records do not provide evidence that 
this has been tried and failed as an outpatient. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. Medicare does not cover a home ventilator for the treatment of obesity hypoventilation 
syndrome, or when used at settings that can be provided with 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 the NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood glucose test strips and supplies (A4253, A4259). 
 
You asked the Plan to pre-approve the test strips and supplies. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 
  The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve 
blood glucose test strips and supplies (A4253, A4259).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve polatuzumab vedotin-piiq with rituximab-pvvr, 
cyclophosphamide, doxorubicin, and prednisone. 
 
You asked the Plan to pre-approve the requested combination treatment. You say that this treatment is 
medically necessary.  The Plan denied your request. The Plan says that the guidelines do not support this 
treatment at this time.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 combination treatment. 
Our reviewer says that the requested combination treatment is found to be medically reasonable and necessary.  
Our physician reviewer found polotuzumab is FDA-approved for the treatment (in combination with a 
rituximab product, cyclophosphamide, doxorubicin, and prednisone; R-CHP) of previously untreated diffuse 
large B-cell lymphoma, in adults with not otherwise specified or high-grade B-cell lymphoma and with an 
International Prognostic Index score of 2 or greater. This patient has at least an R-IPI of 2. The service is 
reasonable and 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 combination treatment have not been met. Therefore, we decided 
that the Plan has to pre-approve polatuzumab vedotin-piiq with rituximab-pvvr, cyclophosphamide, 
doxorubicin, and prednisone.  
 
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 pre-approve insertion of pacemaker pulse generator. 
 
You asked the Plan to pre-approve insertion of pacemaker pulse generator. You say that insertion of pacemaker 
pulse generator is medically necessary. The Plan denied your request. The Plan says the requested insertion of 
pacemaker pulse generator is 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 insertion of pacemaker pulse generator. 
Our reviewer says that the requested insertion of pacemaker pulse generator is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the echocardiogram has estimated the 
ejection fraction at 52%. American College of Cardiology/American Heart Association/ Heart Rhythm Society 
guidelines and also American College of Cardiology/American Heart Association Heart Failure guidelines suggest that cardiac resynchronization therapy (CRT) can be useful in patients with atrial fibrillation who have 
a left ventricular (LV) ejection fraction less than 35% on guideline-directed medical therapy if the patient 
requires ventricular pacing or otherwise meets CRT criteria, and if atrioventricular (AV) node ablation or 
pharmacologic rate control will allow near-100% ventricular pacing with CRT. However, there is no history of 
documented, non-reversible, symptomatic bradycardia for which a pacemaker has been indicated. There is no 
documentation of significant left ventricular dysfunction. In summary, there is insufficient documentation to 
support the medical necessity for implantation of a bi-ventricular pacemaker.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of pacemaker pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of pacemaker pulse generator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methadone assisted treatment provided from August 1, 
2022, to August 22, 2022, by an OON provider. 
 
You asked the Plan to pay for the methadone assisted treatment. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says these services were not 
authorized. 
 
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. The rules also 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. 
 
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 the methadone assisted treatment have 
been met. Specifically, the provider did not submit records or copies of claims that were previously paid by the 
Plan. Therefore, we decided that the Plan does not have to pay for the methadone assisted treatment provided 
from August 1, 2022, to August 22, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive 
pulmonary disease (COPD) with hypercapnic and hypoxemic respiratory failure. He has chronic respiratory 
failure. He has failed bi-level positive airway pressure (BiPAP) therapy with average volume-assured pressure 
support (AVAPS). BiPAP therapy is not documented as able to improve the enrollee's chronic respiratory 
failure. The home ventilator is therefore reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a home ventilator.  
 
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.