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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has COPD, chronic repository 
failure and elevated PAC02. The device is medically necessary. The Plan denied your request. The Plan says 
the request for a non-invasive ventilator (NIV) is not medically necessary because the documentation does not 
support that this device meets but does not exceed the enrollee's need. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD 
and was recently hospitalized. An ABG was consistent with acute on chronic hypercarbic respiratory failure. 
There are no pulmonary function tests, and no ABG done while stable to document chronic CO2 retention. If 
that is present, the enrollee may benefit from BiPAP with AVAPS during sleep. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for unspecified laboratory testing (87799) and related tests provided on 
March 1, 2023. 
 
You asked the Plan to pay for unspecified laboratory testing and related tests. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
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 has denied the claim for March 1, 2023, because non-
specific procedure code 87799 was not reported with additional information to identify the services provided. 
Our review of the claim indicates that code 87799 was reported with a unique identifier code assigned by the 
DEXTM Diagnostics Exchange. The Plan has not provided a rationale for denying the other lines on the claim. 
 
It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denials have not been 
supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for unspecified 
laboratory testing (87799) and related tests provided on March 1, 2023.  
 
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 procedure code 67820 billed for date of service January 16, 
2023.  
 
You asked the Plan to pay for procedure code 67820. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 67820 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 67820 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 67820 billed for date of service January 16, 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. The Plan denied your request. The Plan says it is not 
safe for the enrollee to leave the hospital at this time because ongoing fevers and bleeding that need further 
investigation. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the additional physical therapy 
visits are medically necessary. The Plan denied your request. The Plan says 10 additional physical therapy 
visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. The enrollee has no recent 
injury or a decline in function. The additional therapy services are not appropriate duration and frequency for 
treatment of the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physical therapy visits. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (64635, 64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is 
not medically necessary because the records show you have not had at least 2 prior medial branch blocks with 
80% sustained relief. 
 
The Plan follows Medicare rules. Medicare rules say that in order for thermal radiofrequency destruction of 
lumbar paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must 
have had at least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
   
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance. Our reviewer says that the requested service is not 
medically reasonable or necessary. Our physician reviewer found here is no documentation of 2 sets of 
diagnostic MBBs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a knee arthroplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Plan criteria. 
 
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 knee arthroplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. This includes any formal physical 
therapy. Additionally, there are no examinations provided for review to corroborate any subjective and/or 
objective findings to support the radiograph confirmed severe left knee osteoarthritis is causing deficits. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 knee arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroplasty (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found the documentation does not indicate the member 
has an appropriate diagnosis for treatment with a high frequency chest wall device and vest. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has had minimally invasive lumbar 
decompression at  L4-l5, the levels requested for treatment. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you cannot breathe at night at all. The 
requested device is medically necessary. The Plan denied your request. The Plan says the request for a non-
invasive ventilator (NIV) is not medically necessary because the documentation does not support that this 
device meets but does not exceed your need. 
 
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 service is not medically necessary. Our physician reviewer found you have obesity hypoventilation 
syndrome and atrial fibrillation. You were hospitalized on June 15, 2023, with cardiac tamponade from 
hemopericardium, related to anticoagulation. Initial ABG showed acute hypercarbic respiratory failure. PaCO2 
remained elevated in the hospital despite use of BiPAP during sleep. Spirometry as an inpatient on June 22, 
2023, was of poor quality, consistent with severe restrictive disease. There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease. There is no documentation of chronic CO2 retention with an 
ABG done while stable. If that is present, you may benefit from BiPAP with AVAPS during sleep. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC. You say that the requested PWC is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the PWC is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the PWC is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair. You say that an ultralightweight wheelchair 
is a necessity for your care. The Plan denied your request. The Plan says an ultralightweight wheelchair for use 
outside the home is not a covered benefit. 
 
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 pre-approve an ultralightweight wheelchair (K0005).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307 and G0482) provided on 
January 4, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and was ordered 
by the enrollee's physician. The Plan denied your request. The Plan says these services are not supported in the 
medical record. 
 
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 drug testing have been met. 
Specifically, the only record provided for these services is an order form. No results were provided to support 
these services were performed as reported. Therefore, we decided that the Plan does not have to pay for drug 
testing services (80307 and G0482) provided on January 4, 2023.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that you need an intensive team 
for your care. Services needed may be provided safely in a lower level of 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 17, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on January 17, 
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 inpatient rehabilitation is the most 
appropriate discharge disposition form the enrollee given prior active lifestyle and current acute chronic 
medical needs. The Plan denied your request. The Plan says the enrollee does not need to criteria for admission. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 laboratory services related to end-stage renal disease 
(ESRD) provided on January 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
11, 2023.