Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 2, 2023, to 
March 23, 2023. 
 You asked the Plan to pay for the home health services. You say that payment should not have been denied in 
full, only reduced. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 21, 2023. The NOA was not received by the Plan until April 19, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 2, 2023, to March 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 91035 billed for date of service January 19, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is 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 91035 is esophagus, gastroesophageal reflux test; with 
mucosal attached telemetry pH electrode placement, recording, analysis and interpretation. We find that CPT 
code 91035 is not supported in the medical record. The records do not include a written interpretation report of 
the reflux test. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for 91035 billed for date of service 
January 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 13, 2023, to May 
10, 2023. 
 You asked the Plan to pay for the home health services. You say that you timely submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although you indicated that a NOA was submitted, none has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from April 13, 
2023, to May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator with humidifier.  
 
You asked the Plan to pre-approve a home ventilator with humidifier. You say that the enrollee requires 
AVAPS and tidal volume. 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 with humidifier. Our 
reviewer says that a home ventilator with humidifier is not medically necessary. Our physician reviewer found 
that the enrollee has COPD and chronic respiratory failure. The enrollee also had a recent admission for COPD 
exacerbation in which they responded well with BiPAP therapy. The enrollee's documentation does not support 
BiPAP failure. Therefore, a home ventilator is not 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 a home ventilator with humidifier have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator with humidifier.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the colonoscopy services provided on 
March 20, 2023. 
 
You asked the Plan to reduce the cost share for the colonoscopy services. You say that the deductible should 
not apply. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $800 deductible which applies to hospital services. Your contract with 
the Plan also clearly says that you must pay 10% of the approved amount for hospital services. The annual 
deductible applies. You have been asked to pay $751.12, which satisfies the deductible for the colonoscopy services. The service 
you asked the Plan to reduce the cost share for falls within the hospital services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to 
hospital services. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy 
services was received on March 20, 2023.  
 
You have also been asked to pay $283.69, which is 10% coinsurance of the allowed amount for the 
colonoscopy services ($2,836.98 allowed amount x 10% = $283.69). The total amount you owe is $1,034.81 
($751.12 deductible + $283.69 coinsurance = $1,034.81). This service falls within the hospital services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to reduce the cost share for the colonoscopy services provided on March 
20, 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 the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee has exhausted the number of hospital days covered. 
 
The Plan must follow Medicare rules. 
 
We looked at 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 5, 2022, to 
October 4, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was timely filed. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 5, 2022. The NOA was not received by the Plan until November 
25, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 5, 2022, to October 4, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 17, 2021. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice on the date 
of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 14, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on December 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that due to the enrollee's medical needs SNF care would 
provide the services they need in order for them to recover. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you can't go home because of all of the stairs, and 
you cannot care for yourself. The Plan denied your request. The Plan says criteria for admission to the SNF 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that you believe this test is medically 
necessary for this case to diagnose the source of the gastrointestinal bleeding. The Plan denied your request. 
The Plan says the video capsule endoscopy requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that the indications for a wireless capsule endoscopy are 
listed in the Medicare rules section of this letter. 
 
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 capsule endoscopy. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the fecal occult blood is 
negative and documentation does not show that the anemia is iron deficient in nature, so a capsule endoscopy is 
not indicated and does not satisfy LCD criteria. 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x3). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that enrollee continues to require supervision with ambulation and some appropriate 
skilled therapy goals have not been met but the 5 approved home health physical therapy sessions would be 
expected to be sufficient to meet the stated goals. The records do not show that 3 additional skilled physical 
therapy visits are required in the home to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x3).
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; lumbar or sacral, single facet joint (64635). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance; lumbar or sacral, single facet joint. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary not covered. Medicare rules also 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; lumbar or sacral, single facet joint. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found there is no documentation 
that at least 50% pain relief for 6 months was achieved with prior injection. 
 
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; lumbar or sacral, single facet joint 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; 
lumbar or sacral, single facet joint (64635).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 25, 2022, to 
October 29, 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 
DRG billed was appropriate for the services performed. The Plan denied your request. The Plan says the billed 
principal diagnosis of J96.01 (acute respiratory failure with hypoxia) is not supported in the medical record. As 
a result, a lower DRG was paid. 
 
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 a principal diagnosis of J96.01 (acute respiratory 
failure with hypoxia). 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 reviewer says that the billed principal diagnosis of J96.01 (acute 
respiratory failure with hypoxia) is not supported by the medical record. Our physician reviewer found the 
enrollee was a 63-year-old man with history of small cell lung cancer who presented with shortness of breath. 
The enrollee had a computed tomography (CT) scan which showed no pulmonary embolism. He was placed on 
nasal cannula but there is no documentation of hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 25, 2022, to October 29, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the out-of-network CTA. You say that you had surgery a year ago and are 
going back to the provider for a CTA. You say you would like to follow up at the same facility that you had 
surgery. The Plan denied your request. The Plan says based on Medicare guidelines, the request to use an out-
of-network provider for your services does not meet the requirements for approval. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomographic angiography (CTA) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, other 
than spinal applications (E0747). 
 
You asked the Plan to pre-approve osteogenesis stimulator. You say that the enrollee needs the bone stimulator 
as soon as possible. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the device. 
 
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 osteogenesis stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical documentation supports that the enrollee underwent a Lapidus 
bunionectomy on May 18, 2023. As of August 2, 2023, the enrollee continues to suffer with pain and swelling 
to the first tarsometatarsal joint, consistent with the possibility of a pseudarthrosis / delayed union. As of the 
writing of this review September 21, 2023, that is roughly 4 12 months since the date of surgery. The criteria for 
use of an osteogenic bone stimulator have not been met, in that nine months has not elapsed since the last 
surgery. Therefore, the enrollee does not meet the criteria for the osteogenic bone stimulator and the device 
cannot be considered medically reasonable or 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 osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, other than spinal applications 
(E0747).