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 requested ventilator is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary 
because records were not received with sleep oximetry to support the use of non-invasive ventilation. 
 
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 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records do not 
clarify that the home ventilator will not be used exclusively in a bilevel positive airway pressure mode that 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the admission is not medically 
necessary beginning August 13, 2023. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient psychiatric services are medically necessary. Our physician 
reviewer found the provided documentation indicates that the enrollee was still undergoing active treatment 
and medication adjustments. Therefore, the reviewer found that the request for continued inpatient psychiatric 
services is medically 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve continued inpatient psychiatric 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96366) provided on November 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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. 
 
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 use of code 96366 is not supported by the records provided. Our reviewer found that the record states that a continuous insulin 
infusion was administered with monitoring of blood glucose levels. There is a more specific code to report this 
service. 
 
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 the services (96366) provided on November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of multi-component, inflatable penile 
prosthesis (54405) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service can be provided 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. 
 
You are not a network provider with the Plan. The Plan has confirmed there are 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 the insertion of multi-
component, inflatable penile prosthesis (54405) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee is having symptoms. You 
say that the enrollee has had recurring hospital visits. You also say that the enrollee would benefit from this 
procedure due to recurrent heart failure. The Plan denied your request. The Plan says this device 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 a CardioMEMS device. Our reviewer 
says that the requested a CardioMEMS device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer found that the requested CardioMEMS system is not medically reasonsble 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 need intensive rehab in order to fully recover. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on September 26, 2022, to 
September 30, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee presented with sepsis due to pneumonia. The Plan denied your request. The Plan says that the 
diagnosis code was not supported clinically.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our physician reviewer found that the enrollee has a history of chronic 
obstructive pulmonary disease. The enrollee presented with fever, chills, productive cough, and was diagnosed 
with pneumonia. The enrollee was treated with antibiotics (ceftriaxone) and discharged on a course of 
Augmentin. The enrollee had leukocytosis to 21,700. The enrollee had systemic inflammatory response 
syndrome with pneumonia as a source. Therefore, the documentation meets the criteria for the billed diagnosis 
code, A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on September 26, 2022, to September 30, 2022, at the Diagnosis Related 
Group (DRG) originally 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
10, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient procedures for date of service March 1, 2022. 
 
You asked the Plan to pay for the outpatient procedures. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services on claims must be submitted correctly to 
be processed. 
 
We looked at the file and Medicare rules. Review of the file shows that the clam is not payable as billed. Based 
on this information, we decided that Medicare rules for coverage of the outpatient procedures have not been 
met. Therefore, we decided that the Plan does not have to pay for the outpatient procedures for date of service 
March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the enrollee has a compression fracture. The 
Plan denied your request. The Plan says the medical criteria has not bene 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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no trial of bracing and there is fracture retropulsion which is a contraindication. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered air flotation bed (low air loss therapy) 
(E0193).  
 
You asked the Plan to pre-approve a powered air flotation bed . You say that the enrollee cannot change their 
position because they cannot move their legs or sleep on the side.  The Plan denied your request. The Plan says 
the requested pressure reducing support surface is not medically necessary under Medicare. 
 
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 powered air flotation bed. 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 reduced bed mobility and is non-ambulatory due to 
weakness and spasticity form cerebral palsy. The enrollee is noted to have bilateral pressure wounds with 
ulceration of the heels due to ankle foot orthoses and these were adjusted with additional padding. The enrollee 
is also noted to be wearing heel protectors at night. The enrollee does not have stage II or greater pressure 
wounds of the trunk or pelvis. Therefore, the powered air flotation bed (E0193) is 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 a powered air flotation bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered air flotation bed (low air loss therapy) (E0193).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure (58999) provided on August 29, 2022. 
 
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the surgical codes that are included on the ASC 
list of covered surgical procedures are separately paid under the OPPS, have been determined to pose no 
significant safety risk to Medicare beneficiaries when furnished in ASCs, and for which standard medical 
practice dictated that the beneficiary would not typically be expected to require active medical monitoring and 
care at midnight following the procedure.  
 
We looked at the file and Medicare rules. In this case, code 58999 is not listed as a covered code on the ASC 
list. Based on this information, we decided that Medicare rules for coverage of the procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for the procedure (58999) provided on August 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on April 
6, 2023. 
 
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 there is a more appropriate code to use in this case. 
 
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 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 codes in question are not 
supported. The record states that a continuous infusion of insulin was performed with close monitoring of 
glucose levels. There is a more specific code to report this procedure.  
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 codes 96365, 96366, and 96521 rendered on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 12, 2022, to 
May 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the required services could have been provided at an 
observation level. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was responding to initial treatment and not requiring complex procedures 
or treatment with stable vitals, it was not expected that the enrollee would require hospital care that would have 
likely crossed two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided May 12, 2022, to May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peri-implant capsulectomy. 
 You asked the Plan to pre-approve a peri-implant capsulectomy. You say that the enrollee states that there are 
painful episodes periodically pulling across from the lateral chest. The Plan denied your request. The Plan says 
this is a cosmetic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 peri-implant capsulectomy. Our 
reviewer says that the requested service is not medically necessary. Our reviewer found the enrollee has 
undergone repeat breast implant revision following bilateral mastectomies for breast cancer in the distant past. 
The record provided does not establish presence of an enumerated condition for which coverage is available 
under the rules. 
 
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 peri-implant capsulectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peri-implant capsulectomy.
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 are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval 
of a ventilator. 
 
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 COPD, lung cancer, 
lymphoma, and atrial fibrillation.  A home ventilator was prescribed following a hospitalization in 2021. An 
arterial blood gas on June 12, 2021, was consistent with acute on chronic hypercarbic respiratory failure. There 
is no documentation that the home ventilator is being used. The medical record does not show that bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) has been tried 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).