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 you need continuation of a ventilator due to 
having flare-ups and having trouble with your oxygen. You need the device to live and breathe normally back 
to health. The Plan denied your request. The Plan says you do 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 you have severe COPD and were 
prescribed a home ventilator following a hospitalization in April.  The records include venous blood gases from 
the hospitalization that do not convincingly show carbon dioxide (CO2) retention. There is no arterial blood gas 
done while stable to document chronic CO2 retention. If that is present, you may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for November 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99223 is not supported by the submitted records. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99223 
is not supported by the submitted records. Our reviewer found the submitted note for the date of service 
includes a medically-appropriate history, including detail that the enrollee was slumping in a chair at home and 
found to have hypotension, which was resolved at the time of the meeting. The examination was brief and not 
comprehensive. Workup included imaging to rule out a stroke and other acute conditions. However, the plan 
included staying off antihypertensives, check orthostatics, transesophageal electrocardiogram (TEE), carotid 
Doppler and Holter monitor with neurology to follow-up. However, this does not describe a high level of 
medical decision making or a comprehensive history to justify code 99223.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for November 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Sprint peripheral nerve stimulator (PNS) 
(63650, 64555). 
 
You asked the Plan to pre-approve a Sprint PNS. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Sprint PNS. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that use of the requested device is considered experimental for shoulder pain as described.  
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a Sprint peripheral nerve stimulator (PNS) (63650, 64555).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended sleep study (95810). 
 
You asked the Plan to pre-approve an attended sleep study. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this enrollee does not have a qualifying comorbid condition, chronic 
opioid medication use or suspicion of a sleep disorder other than OSA that could degrade the accuracy of a 
home sleep study. 
 
The Plan follows Medicare rules. 
 
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 an attended sleep study. Our reviewer 
says that the enrollee meets criteria for coverage. Our physician reviewer found the enrollee has a prior study, 
not provided, and history of a diagnosis of OSA.  A sleep study is warranted to diagnose and treat the patient 
presumptive diagnosis and symptoms. For continued care and management, a sleep study would have been 
repeated likely by now, if in fact, it has been 6 years. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have been met. Therefore, we decided that the Plan has 
to pre-approve an attended sleep study (95810).  
 
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 practitioner services provided on February 21, 2023, billed 
with procedure codes 96365-59 and 96366-59 (x2). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 96365 and 96366 is intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case, there is a more specific 
code that should be reported to support service documented.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 21, 2023, billed with procedure 
codes 96365-59 and 96366-59 (x2).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324).  
 You asked the Plan to pre-approve Orthovisc. You say that the request is medically necessary. The Plan denied 
your request. The Plan says that step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
criteria for coverage of Orthovisc have not been met. Our physician reviewer found the enrollee has not trialed 
a preferred viscosupplemental treatment such as Synvisc, Synvisc-One, or Euflexxa. Step therapy, as outlined 
by the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered or that the Plans additional required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, 
Orthovisc is not approved as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer.  
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied 
your request. The Plan says a trial of Venofer is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable continuous positive airway pressure (CPAP) 
machine for travel (E1399).  
 
You asked the Plan to pre-approve a portable CPAP machine for travel. You say that you are traveling out of 
the area, and you are unable to take your current CPAP machine with you. The Plan denied your request. The 
Plan says Medicare only covers an item when it is used for a medical need and not for comfort, convenience, or 
self-help need. A portable CPAP machine is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP device. A CPAP device serves the same purpose as a portable CPAP 
machine for travel. Therefore, we decided that the Plan does not have to pre-approve a portable continuous 
positive airway pressure (CPAP) machine for travel (E1399).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended sleep study (95810). 
 
You asked the Plan to pre-approve an attended sleep study. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the provider does not say that the enrollee has any health problems that 
may affect results for a home sleep test. 
 
The Plan follows Medicare rules. 
 
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 an attended sleep study. Our reviewer 
says that the enrollee meets criteria for coverage. Our physician reviewer found the enrollee's history and 
symptoms, as well as his scores for risk of sleep apnea and concerning for a diagnosis of OSA warrant a sleep 
study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have been met. Therefore, we decided that the Plan has 
to pre-approve an attended sleep study (95810).  
 
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: 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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF. 
 
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 enrollee is medically stable. While the medical record supports a need for 
physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service January 2, 
2023. 
 You asked the Plan to pay for procedure code 74176. You say that there are no bundling issues. The Plan 
denied your request. The Plan says payment for code 74176 is bundled into payment for code 74178. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 74176 is a column II code to column I code 74178. Code 74176 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74176 
billed for date of service January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lenses, scleral, gas permeable (V2531) and 
fitting of contact lenses for management of keratoconus, initial fitting (92072). 
 
You asked the Plan to pre-approve contact lenses and fitting. You say that the regular contact lenses do not 
work. The scleral lenses are needed to keep your eyesight functioning for your daily life. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. Specifically, contact lenses are only covered after cataract surgery. 
Based on this information, we decided that the Plan's rules for coverage of contact lenses and fitting have not 
been met. Therefore, we decided that the Plan does not have to pre-approve contact lenses, scleral, gas 
permeable (V2531) and fitting of contact lenses for management of keratoconus, initial fitting (92072).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the enrollee to have some 
independence going outside because they feel like a burden to their family. You also say that the enrollee can 
only walk short distances before their legs give out. The Plan denied your request. The Plan says Medicare 
criteria are not met, and medical necessity is not established. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power scooter. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee currently uses a 
wheelchair. Our reviewer also found that the records do not indicate the wheelchair is inadequate to meet the 
enrollee's need for support to perform MRADLs in the home 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (E1230).
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 the enrollee is barely able to walk due to injuries. 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does 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 the enrollee 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: 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 services are medically necessary for 
the enrollee to receive the appropriate level of care. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the 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.