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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the daily use of volume mechanical 
ventilation has been shown to reduce lung hyperinflation and provide periods of rest for the enrollee's overall 
function, mobility and prevent a rapid decline in health and hospital readmission. The Plan denied your request. 
The Plan says the request for a home ventilator set in AC mode with 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 service is not medically necessary. Our physician reviewer found the enrollee has severe COPD, but 
there is no arterial blood gas documenting chronic CO2 retention. If that is present, the enrollee 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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for date of service October 15, 2022. 
 
You asked the Plan to pay for code 99232. You say that the physician performing these services was the on-call 
physician, so this claim should be paid. The Plan denied your request. The Plan says you billed with an 
inappropriate pair of diagnoses on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition. 
 
In this case, you billed with the following diagnoses: J36 (peritonsillar abscess), and J03.90 (acute tonsillitis, 
unspecified).  According to the code tables that Medicare publishes, diagnosis code J36 lists code J03.90 as an 
Excludes1 code.  This means that these two diagnosis codes should not be billed together on the same claim. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99232 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99232 billed for date of service October 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 6, 2022, 
through July 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says an admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 6, 2022, through July 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) freestyle libre 
sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the Plan has already approved a freestyle 
libre 14 sensor. The record does not indicate that an upgrade to the freestyle libre 2/3 sensor is 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) freestyle libre sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only (93010) provided on September 20, 2022. 
 
You asked the Plan to pay for an electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service 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 93010 is an electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only. 
 
 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 an electrocardiogram. Our reviewer says that the service is 
not medically necessary. Our reviewer found the documentation does not contain evidence of an 
electrocardiogram (ECG) or the professional interpretation for the date of service in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram, routine ECG with at least 12 leads; interpretation and report 
only (93010) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care provided on April 18, 2022, by an out-
of-network (OON) provider.
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 are unable to breathe and need the authorization 
approved so you can receive further treatment. The Plan denied your request. The Plan says you do not meet 
the guidelines 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve (64628). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the magnetic resonance imaging (MRI) shows spinal stenosis. The cause of the enrollee's back pain 
is not clear. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve (64628).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on June 7, 2022, billed with codes 
95907-TC, 95887-TC, and 95840-59. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this charge is included in the facility benefit. You 
should bill the facility.  
The Plan must follow Medicare rules. Medicare rules say that payment for physicians radiological services to 
the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the 
radiology service, is made by the A/B MAC (A) to the hospital as a provider service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. Therefore, we decided that the Plan does not have 
to pay for testing services provided on June 7, 2022, billed with codes 95907-TC, 95887-TC, and 95840-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a new (acute) medical, surgical, or 
neurological condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease 
in functional ability such that they cannot adequately recover in a less intensive setting. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve cardiac computed tomography (CCT) angiography. 
 
You asked the Plan to pre-approve CCT angiography. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that this test is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that CCT angiography may be 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 CCT angiography. Our reviewer says 
that the enrollee meets criteria for the requested scan. Our physician reviewer found the CCT angiography is 
for evaluation of cardiac arrhythmia and previously documented stress test. This addition to the enrollee's 
testing is reasonable in a patient with a complex past medical history. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCT angiography have been met. Therefore, we decided that the Plan has to 
pre-approve cardiac computed tomography (CCT) angiography.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an extra heavy-duty manual wheelchair (K0007). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you have had an amputation. You say 
that your foot has been operated on three times. You say that you have staph infections that have not cleared 
up. You also say that you need this wheelchair to get to and from the bathroom. The Plan denied your request. 
The Plan says that the evidence of mobility limitation that significantly impairs MRADLS is not clear. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair may be covered when certain 
criteria have been 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 a manual wheelchair. Our reviewer says 
that the extra heavy duty manual wheelchair is medically necessary. Our physician reviewer found while the 
enrollee may be able to use a walker, the enrollee is not a functional ambulator with this device and requires a 
manual wheelchair for mobility in performing daily activities. The reviewer found that the enrollee meets the weight requirement for the requested extra heavy duty manual wheelchair. The reviewer also found that the 
enrollee can propel and use the requested manual wheelchair. Therefore, the reviewer found that the requested 
for an extra heavy-duty manual wheelchair (K0007) is 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 a manual wheelchair have been met. Therefore, we decided that the Plan has to 
pre-approve an extra heavy-duty manual wheelchair (K0007).  
 
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 ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are improving and feel disappointed 
that the Plan is denying services that are helping. The Plan denied your request. The Plan says the request for 
additional physical therapy visits is not medically necessary. 
 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 therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy test (81455) provided 
December 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this letter and the attached documents support 
the medical necessity of the test requested, to assist in the treatment prognosis, and diagnosis for this type of 
cancer. The Plan denied your request. The Plan says under Medicare guidelines, this Tempus xF liquid biopsy 
test does not meet the requirements for approval as it is not FDA approved. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the Tempus xF liquid biopsy test (81455) provided December 15, 2022.
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 the enrollee has a progressive disease and 
trilogy was needed to slow progression of the enrollee's respiratory failure and delay death. The Plan denied 
your request. The Plan says the request for continued use of a non-invasive ventilator (NIV) is not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated 
in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not 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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).