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

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the enrollee is able to use a walker and is ambulatory in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when the criteria 
listed in the Medicare Rules section is met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift or glide.  
 
You asked the Plan to pre-approve a stair lift or glide. You say that you would like reconsideration because the 
requested stair lift is medically necessary. The Plan denied your request. The Plan says the requested stair lift is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift or glide.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says an inpatient stay of three consecutive days or more is required to qualify for the SNF 
benefit. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have 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 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 SNF care.
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 can continue to receive their ongoing acute care needs 
at the current acute care setting already approved by the health plan.  
 
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 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. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 6, 2022, to April 
4, 2022. 
 You asked the Plan to pay for the home health services. You say that these services do not require prior 
authorization. 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 March 6, 2022. The NOA was not received by the Plan until May 5, 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 
March 6, 2022, to April 4, 2022.
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 services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternate setting.  
 
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 does not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item should be covered.  You did not 
provide a specific argument with your appeal request. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient. A bilevel positive airway pressure (BiPAP) device with 
average volume-assured pressure support (AVAPS) would meet the patient's needs. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found this patient has a diagnosis of 
COPD, although the records do not include pulmonary function tests to confirm airway obstruction or assess 
severity.  There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no arterial 
blood gas done while stable to document chronic CO2 retention.  If that is present, the patient may benefit from 
BiPAP with AVAPS during sleep.  Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device billed with code E0675 
for dates of service July 21, 2022, to August 10, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device has been proven 
efficacious by medical literature. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 
are non-covered.  The pneumatic compression device at issue in this appeal was billed with code E0675.  This 
means that this item is not covered, regardless of appropriateness. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device billed with code E0675 for dates of service July 21, 2022, to 
August 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service January 23, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the enrollee had multiple examinations on 
this date of service. The Plan denied your request. The Plan says payment for code 99284 is bundled into 
payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. This claim 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 99284 billed for date of service January 23, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 6, 2020. 
 
You asked the Plan to pay for the medical services. You say that this claim has not been paid in full. The Plan 
denied your request. The Plan says you did not timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical services was not filed until March 14, 2022. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
medical services provided on September 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve the medication. You say that this is needed by the enrollee. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fasenra.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard wheelchair with related accessories. 
 
You asked the Plan to pre-approve the standard wheelchair with related accessories.. You say that the item 
should be covered. The Plan denied your request. The Plan says Medicare does not cover durable medical 
equipment (DME) in a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the standard wheelchair with related accessories. is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve the standard wheelchair with related 
accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for this scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET scan. Our reviewer says that the 
enrollee does not meet criteria for this PET scan. Our physician reviewer found there is no computed 
tomography (CT) report and no mention of a pulmonary nodule requiring metabolic evaluation with PET/CT. 
If there is a nodule on CT, PET is not indicated unless the nodule exceeds 8 millimeters in diameter due to the 
inherent resolution challenges with PET. Absent any report showing a nodule the medical necessity of the 
requested PET scan has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has started chemotherapy. You 
also say that the enrollee needs this medication to control the resulting nausea and vomiting. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prochlorperazine.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97026, 95851 and 97164 billed for date of 
service January 5, 2023, to February 7, 2023. 
 
You asked the Plan to pay for procedure codes 97026, 95851 and 97164. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says payment for codes 95851 and 
97164 is bundled into payment for codes 97140 and G0283. In addition, infrared light therapy (97026) is not a 
covered service under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that infrared light therapy 
services are not covered by Medicare. 
 
In this case, we have confirmed that codes 95851 and 97164 are column II codes to column I codes 97140 and 
G0283. These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. In addition, code 97026 is for infrared therapy, which is 
not a covered service according to Medicare rules. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97026, 95851 and 97164 billed for date of service January 5, 2023, to February 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
October 23, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says independent freestanding emergency department 
services are covered as a hospital only upon CMS approval. This provider has not provided proof of CMS 
approval nor does the CMS Outpatient PPS file reflect CMS approval.  
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services is the appropriate level of care for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria for IRF admission was not met. 
 
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 that 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 was admitted for myocardial infarction, gastrointestinal bleeding, and anemia. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  
 
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 this 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22514), computed tomography (CT) 
scan for needle biopsy (77012), and bone biopsy (20225). 
 
You asked the Plan to pre-approve L3 kyphoplasty, CT scan for needle biopsy, and bone biopsy. You say that 
this is medically necessary. The Plan denied your request. The Plan says there is no documentation of any non-
surgical management. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L3 kyphoplasty, CT scan for needle 
biopsy, and bone biopsy. Our reviewer says that you do not meet criteria for coverage. Our physician reviewer 
found the formal diagnostic imaging studies were not provided for review to corroborate any acute/subacute 
osteoporotic vertebral fractures. Also, without formal diagnostic studies, other potential causes of lumbar pain 
cannot be ruled out. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty, CT scan for needle biopsy, and bone biopsy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve L3 kyphoplasty (22514), computed 
tomography (CT) scan for needle biopsy (77012), and bone biopsy (20225).
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 would benefit from the level 
of LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and does not require transfer to an 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  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. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.