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

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Provided records document that the home 
ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode which is a 
modality that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service April 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the bill type is correct. The Plan denied your 
request. The Plan says the claim was billed with an invalid type of bill. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was submitted with type of bill code 323. This code is 
not among those suitable for payment. 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 the home 
health care billed for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 99379. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99379 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99379 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99379 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99379 billed for date of service June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 30, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 30, 2023, billed with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328 and 81401.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer- assisted navigation/image guidance. 
 
You asked the Plan to pre-approve computer- assisted navigation/image guidance. You say that this is 
medically necessary. The Plan denied your request. The Plan says they do not cover the use of robotic or 
computer-assisted surgical navigation for the enrollee's planned surgery.  
 
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 computer- assisted navigation/image 
guidance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no large volume, long-term/high-quality clinical 
studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of 
computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer- assisted navigation/image guidance have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computer- assisted navigation/image guidance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health care stay 
provided from April 12, 2023, to April 18, 2023. 
 
You asked the Plan to waive the copayment for the inpatient mental health care stay. You say that you did not 
need this inpatient stay. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment per day for days 1-4 of each benefit period for mental health care stays. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for days 1-4 of each benefit period for mental health 
care stays. 
 
You have been asked to pay a $395 copayment per day for days 1-4 of the inpatient mental health care stay. 
This item/service falls within the inpatient services in a psychiatric hospital benefit category. You have not 
been asked to pay after day four or for the day you were discharged. You have been asked to pay a total of 
$1,580 for the inpatient mental health car stay ($395 copayment per day x 4 days = $1,580). 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 waive the copayment for the inpatient mental health care stay provided from April 12, 2023, to 
April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on March 10, 2023, to March 
14, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says that the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code E43. 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 use of diagnosis code E43 is supported by the records provided. Our physician reviewer 
found that the patient is underweight with very low albumin, and was treated for malnutrition As such, a 
diagnosis of severe protein-calorie malnutrition and diagnosis code E43 are justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on March 10, 2023, to March 14, 2023, at the Diagnosis Related Group 
(DRG) originally billed.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin infusions provided form June 3, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that these infusions have been very effective in 
boosting your depleted immune system. You say that these services were previously paid for from March 2021 
to July 2021 and now they are being denied. You also say that you feel that treatment and preventive care is 
being denied. The Plan denied your request. The Plan says the infusion services are 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 pay for the outpatient services. Our reviewer says 
that the requested vitamin infusions were not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no specific clinical rationale for the vitamin infusions. The reviewer found that there is no support in the medical literature for vitamin infusion therapy for the treatment of the enrollee's 
conditions. Therefore, the reviewer found that the requested vitamin infusions were not medically reasonable or 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the vitamin infusions provided form June 3, 2021, to December 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63056 and 63057 billed for date of service 
March 31, 2023. 
 
You asked the Plan to pay for procedure codes 63056 and 63057. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
billed. 
 
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 63056 is: Transpedicular approach with decompression 
of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including 
transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc). The definition of 
code 93057 is: Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (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 procedure codes 63056 and 63057. Our reviewer says that 
procedure codes 63056 and 63057 do not meet criteria for payment. Our reviewer found that the provided 
documentation does not contain evidence that spinal cord decompression with a transpedicular approach was 
performed at an initial or subsequent segment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 63056 and 63057 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 63056 and 63057 billed for date of service March 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87640) provided on January 4, 2023. 
 
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 billed service is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 lab services. Our reviewer says that the 
documentation does not support the billed service. Our physician reviewer found the use of modifier 59 is not 
supported in the records. This service is included in procedure code 87641 which was also billed. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87640) provided on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lifeglider walker. 
 
You asked the Plan to pre-approve a lifeglider walker. You say that you feel this walker is necessary. The Plan 
denied your request. The Plan says the requested walker is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that walkers are only covered for certain 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 a lifeglider walker. Our reviewer says 
that the documentation does not support that the requested walker is medically reasonable or necessary. Our 
physician reviewer found you have multiple sclerosis associated with falls, cervical stenosis, and fibromyalgia. 
The documentation does reveal that you have a mobility limitation that impairs her ability to participate in 
mobility related activities of daily living in the home. The documentation does not support that you have had a 
trial of this walker and that it will improve your mobility related activities of daily living participation and 
safety in your home over a less complex walker. 
 
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 lifeglider walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lifeglider walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says facet joint 
injections are 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 injections. Our reviewer says that 
the enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the previous 
radiofrequency ablation only provided 50% to 60% pain relief for two weeks. Therefore, repeat injections are 
not indicated and the request 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services requested are medically necessary. 
The Plan denied your request. The Plan says that the inpatient rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for IRF admission. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition; the requirements have not been met. The Plan says that the services needed may be 
provided safely in a lower level of care. 
 
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. 
 
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 enrollee requires an LTACH level of 
care and is stable for discharge to that level of care. The Plan denied your request. The Plan says based on 
Medicare guidelines, the LTACH services requested do not meet the requirements for approval.  
 
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 all expected and reasonable care at the acute care hospital. 
There are no specific treatments or services that would be offered at the LTACH that are not available at the 
acute care hospital where the enrollee is 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 long term acute care hospital (LTACH) services.