Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the criteria for approval 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 considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee has been hospitalized and not used skilled services since at least early 
February 2023. The enrollee has a tracheostomy which requires frequent suctioning and a PEG feed. The 
enrollee has daily skilled nursing needs. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 sessions of physical therapy (PT). 
 
You asked the Plan to pre-approve the PT sessions. You say that you had extensive back surgery and need this 
physical therapy to do everyday activities. The Plan denied your request. The Plan says that you have reached a 
plateau in your treatment and have no medical need for continuation of a professionally supervised 
maintenance program.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have received and responded to a course of PT. Your pain persists 
but function and strength are good. You are able to continue with a home exercise program. Continued input 
from a skilled therapist 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 sessions of physical therapy (PT).
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 it is crucial for the patient to receive this 
machine. You also say if the enrollee was to receive the home ventilator, they will benefit by improving the 
quality of their life, exercise capacity, and lower their exacerbations. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in Assist-control (AC) mode with very low tidal volumes 
that could be delivered by BiPAP is not covered. 
 
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 enrollee does not meet the coverage criteria for a home ventilator. Our physician reviewer found the 
provided records in this case document a diagnosis of chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. The records document that the home ventilator is being requested for use with 
very low set tidal volumes (150 to 200 milliliter) which is respiratory assistance that could be provided by a bi-
level positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a 
back-up rate. Our reviewer found that the provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. Our physician reviewer also found that the records in this case do not provide 
adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed to 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Darzalex Faspro. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee is transplant ineligible 
due to his age and comorbidities. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for 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 the enrollee is a 73-year-old for whom admission to a long-term acute care 
hospital (LTACH) has been requested. At issue is whether LTACH services are medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
The enrollee has a medical history that includes stroke, coronary artery disease, COPD, PVD, and DVT. The 
enrollee was admitted to the acute care hospital on May 1, 2023, with acute hypoxic respiratory failure 
requiring intubation. The enrollee was diagnosed with severe sepsis. A diagnosis of squamous cell carcinoma 
of the head and neck was made. Gastrointestinal bleeding developed. A tracheostomy was placed on May 3, 
2023. A PEG tube was placed on May 24, 2023. On May 30, 2023, the enrollee had completed antibiotics. 
Increased work of breathing and suspected pulmonary edema are documented. Long term acute care hospitals 
(LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that 
are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital 
care, and acute care services have not been denied. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where the enrollee is currently receiving care. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (81455) 
provided on December 20, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and request 
reconsideration of payment on this claim. The services were urgently needed, The Plan denied your request. 
The Plan says the requested test is not reasonable and necessary because the provider has not had FDA 
approval or clearance as a companion in vitro diagnostic or an FDA-approved or cleared indication for use in 
this enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the requested test is not FDA approved or has 
clearance as a companion in vitro diagnostic and an FDA approved or cleared indication for use in the 
enrollees cancer. This test does not meet criteria for approval. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for a targeted genomic sequence analysis panel (81455) provided on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing provided on October 24, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0013M is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing provided on October 24, 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 enrollee needs and wants their independence and 
rehabilitation should help them reach that. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare 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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042-59 billed for date of service August 
10, 2022.  
 You asked the Plan to pay for procedure code 11042-59. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11042-59 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11042-59 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11042-59 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional accessories and items (E0955, E2607, E2620, E1007, E1012, E2361, 
E1028, E2311, E2313, E2377, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional accessories and items. 
You say that a complex power wheelchair with tilt and recline is medically necessary for this enrollee to 
provide them with safe mobility within the home and the ability to weight shift independently without relying 
on caregivers. The Plan denied your request. The Plan says the enrollee does not have medical need for 
multiple power options available with K0861 group 3 power wheelchair. The Plan also says an expandable 
controller, harness and electronics are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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 group 3 standard power wheelchair 
and additional accessories and items. Our reviewer says that the enrollee does not meet the coverage criteria for 
a group 3 standard power wheelchair with additional accessories and items. Our physician reviewer found the 
enrollee has a neurologic disorder with functional deficits. The documentation does not indicate that the 
enrollee has any pressure injuries, requires intermittent catheterization of the bladder, or has spasticity that 
would necessitate power tilt or recline. Our reviewer also found that although the enrollees condition may 
meet criteria for a power wheelchair (PWC), the criteria for this specifically requested PWC with multiple 
power options including power tilt and recline are not 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 a group 3 standard power wheelchair and additional accessories and items have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional accessories and items (E0955, E2607, E2620, 
E1007, E1012, E2361, E1028, E2311, E2313, E2377, and K0040).
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 the enrollee does not have support at home and 
needs therapy to maintain daily living. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the negative pressure wound therapy electrical pump 
(NPWT) (E2402) and wound care set (A6550). 
 
You asked the Plan to pre-approve the NPWT and wound care set. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that if criterion A or B is not met, the NPWT pump and 
supplies 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 the NPWT and wound care set. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the records show the 
enrollee has ongoing chronic osteomyelitis that has not been fully treated and does not have continued healing 
with the wound vac use.  
 
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 NPWT and wound care set have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the negative pressure wound therapy electrical pump (NPWT) (E2402) 
and wound care set (A6550).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service January 16, 
2023. 
 
You asked the Plan to pay for procedure code 99253. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.   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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Trivex lenses. 
 
You asked the Plan to pre-approve Trivex lenses. You say that you have hobbies that you work with wood and 
metal, and would like to be able to protect your glasses and eyes. You also say that the requested lenses will 
protect you from sustaining an eye injury. The Plan denied your request. The Plan says that the documentation 
fails to indicate that the requested item is being provided for the diagnosis, direct care, and treatment of your 
medical condition, meets the standards of good medical practice in the local area, and is not mainly for the 
convenience of you or the provider. The Plan also says these lenses are not medically necessary at this time. 
 
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 eyewear including lens options. 
 
We looked at the file and the Plan's rules. The contract clearly states that the Plan covers lens options including 
tint, progressives, and transition lenses, but does not clearly say that the lens options are limited to only these 
three lens types. Based on this information, we decided that the Plan's rules for coverage of Trivex lenses have 
been met. Therefore, we decided that the Plan has to pre-approve Trivex lenses.  
 
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 pre-approve hospital outpatient clinic visits (99213, 99214, 99215, 
99203, 99204, 99205, G0463) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve outpatient clinic visits. You say that the requested facility is the only facility 
within a thirty mile range from your office that offers these services. The Plan denied your request. The Plan 
says the enrollee must receive care from a network provider.  
 
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 
hospital outpatient clinic visits (99213, 99214, 99215, 99203, 99204, 99205, G0463) to be provided by an out-
of-network (OON) provider.