Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 
an LTACH care. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator from September 
1,2023 to October 1, 2023. 
  You asked the Plan to pre-approve a home ventilator from September 1,2023 to October 1, 2023. You say that 
the home ventilator is medically necessary for the enrollee. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS). 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator from September 
1,2023 to October 1, 2023. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found this enrollee has COPD and pulmonary hypertension and was recently hospitalized for COPD 
exacerbation and anemia. The enrollee improved with noninvasive ventilation. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There is no documentation of chronic CO2 retention with 
ABG done while stable. If that is present, may benefit from BiPAP with AVAPS during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
Alarms and backup battery 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 a home ventilator from September 1,2023, to October 1, 2023, have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a home ventilator 
from September 1,2023, to October 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the bone marrow aspirate is not medically necessary. The Plan 
says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have 
not been demonstrated in the peer-review literature.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the bone marrow aspirate is experimental when used as bone graft material. Therefore, the 
service 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 31, 2023. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87498, 87502, 87634, U0003, 87798) provided 
on December 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87498, 87502, 87634, U0003, 87798) provided 
on December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panniculectomy (15830). 
 
You asked the Plan to pre-approve the panniculectomy. You say that  the panniculectomy is medically 
necessary.  The Plan denied your request. The Plan says the panniculectomy 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 panniculectomy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has a pannus following weight loss. The record provided 
does not document the presence of chronic intertrigo refractory to medical treatment for at least three months or 
functional impairment. The elements of the coverage criteria are not satisfied.   
 
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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the panniculectomy (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath / shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested bath / shower chair is medically necessary. The Plan denied your request. The Plan says this item is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath / shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a car lift with swing arm (E1399). 
 
You asked the Plan to pre-approve  a car lift with swing arm. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve  a car lift with swing arm (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a bath tub wall rail / grab bar. You say that you would like reconsideration 
because the requested bath tub wall rail / grab bar is medically necessary. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the Intracept procedure. 
 
You asked the Plan to pre-approve  the Intracept procedure . You say that the Intracept procedure is medically 
necessary.  The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. 
You say the enrollee has chronic low back pain with radiculopathy due to the presence of non-vertebrogenic 
pathology that can explain their source of pain.  
 
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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or stenosis. This means that the cause of pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip Arthroplasty (27130, 27299) to be provided by 
an OON provider.  
 
You asked the Plan to pre-approve total hip Arthroplasty (27130, 27299). You say that you have been seeing 
this provider within the last two months, and you do not want to switch providers. The Plan denied your 
request. The Plan says you must go in-network. There are in-network options available. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 total hip Arthroplasty (27130, 27299). Our reviewer says that the service is 
not medically necessary. Our physician reviewer found that you are being treated for left hip pain. You 
presented with an antalgic gait favoring your left side. You have point tenderness directly over the lateral hip. 
There is discomfort with abduction against resistance. You have been recommended to undergo a total hip 
arthroplasty. However, detailed documentation is not evident regarding any unique clinical presentations for a 
procedure that could not reasonably be provided by an in-network provider. The noted pathology is not an 
uncommon pathology. Therefore, your medical management and/or follow-up care can be safely transitioned to 
an in-network orthopedic surgeon specialist 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 total hip Arthroplasty (27130, 27299) have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve total hip Arthroplasty (27130, 27299). Therefore, we 
decided that the Plan does not have to pre-approve total hip Arthroplasty (27130, 27299) to be provided by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and related equipment. 
 You asked the Plan to pre-approve the oxygen concentrator and related equipment. You say that you have 
difficulty breathing on home O2 and this is a medical necessity.  The Plan denied your request. The Plan says 
the home use of oxygen and related equipment does not meet criteria.  
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator and related 
equipment Our reviewer says that the items are not medically necessary. Our physician reviewer found you 
have adequate O2 saturation on oxygen but no confirmatory evidence or documentation provided which proves 
hypoxemia. You were ill with COVID-19 pneumonia when said saturation required O2 therapy. There is no 
provided arterial blood gas (ABG) or 6 maintenance of wakefulness test (MWT), or desaturations noted in 
documentations provided. Hence, you do not qualify per guidelines for home oxygen therapy with the data 
provided.  
 
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 oxygen concentrator and related equipment have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve an oxygen concentrator and related equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 acupuncture visits (97124). 
 
You asked the Plan to pre-approve 5 acupuncture visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services are being requested for 
treatment of wrist pain. Therefore, we decided that the Plan does not have to pre-approve 5 acupuncture visits 
(97124).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit, and the laboratory services provided on June 
12, 2023, by an OON provider.  
 You asked the Plan to pay for the clinic visit and the lab services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 clinic visit, and the laboratory services 
provided on June 12, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has a wedge compression 
fracture. The Plan denied your request. The Plan says the request does not meet the requirements for approval.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical indications. 
 
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 services. Our physician 
reviewer found that more conservative measures are needed. More oral pain medications and a trial of bracing 
is necessary as well. Therefore, the request is not considered medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
testing. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is experiencing chest pains, 
shortness of breath, and radiation. The Plan denied your request. The Plan says the records do not show that the 
enrollee is unable to perform a maximum exercise workload.  
 
The Plan follows Medicare rules. Medicare rules say that cardiology testing is only covered under certain 
medical indications. 
 
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 services. Our physician 
reviewer found that the requested test was performed for chest pain in 2021 and was normal. There is no 
documentation that the ECG shows an uninterpretable pattern or that the enrollee is unable to exercise. There is 
no evidence provided that would support the need for repeat radionuclide stress testing at this time. Therefore, 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) testing.
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 the enrollee requires a multi-disciplinary 
approach to help his multiple medical and physically complex issues. The Plan denied your request. The Plan 
says the LTACH is not medically necessary, and the enrollees needs are being met in the current hospital 
location.  
 
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 was admitted with pneumonia in the setting of a history of head and neck 
cancer. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied.  
 
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.