Persius/hicric huggingface dataset:
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 you would like an IRF admission to assist you in 
returning to your previous level of independence and activity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for an IRF admission. 
 
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 you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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 (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in PC with AVAPS 
mode 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 you have severe obesity, obesity 
hypoventilation syndrome, obstructive sleep apnea untreated, and HFpEF. You were hospitalized in October 
2022, with acute on chronic hypercarbic respiratory failure requiring intubation. You improved with PAP 
therapy after extubating. There is no diagnosis of COPD, neuromuscular disease, or thoracic restrictive 
disease.  Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on December 1, 2022. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the guidelines state that fungal infection of the nail can be verified 
by direct microscopic examination with potassium hydroxide, fungal culture of desquamated subungual 
material, or fungal stain of a nail clippings fixed in formalin.  
 
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 a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to 
perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific.  
It is unclear as to why this enrollees toenail specimen required PCR testing when other less expensive and 
efficacious lab tests (KOH and fungal culture) are available. Therefore, the requested PCR testing of this 
enrollees toenail was 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 a fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on December 
1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapy cooling reservoir (E1399). 
 
You asked the Plan to pre-approve a therapy cooling reservoir. You say that this was prescribed for medical 
necessity. The Plan denied your request. The Plan says this equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a therapy cooling reservoir have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapy cooling reservoir (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided to the enrollee on July 11, 2022.
You asked the Plan to pay for the F1CDx testing. You say that these services were medically necessary. The Plan denied your request. The Plan says that the provided documentation does not clearly show that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
Our Medical Director looked at the case file and the reopen request. At issue is payment for F1CDx testing. Our Medical Director states that the record originally provided does not document the presence of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The elements of the coverage criteria are not satisfied. The requested service is not recommended. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of the F1CDx testing. 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 F1CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided to the enrollee on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-
shin system, microprocessor control feature, swing and stance phase (L5856). 
 
You asked the Plan to pre-approve lower leg prosthetics. You say that the requested prosthetics are medically 
necessary for the enrollee. The Plan denied your request. The Plan says Medicare guidance says that the 
requested computerized knee exceeds the enrollee's needs. There is a request for parts for your leg prosthesis. 
There are other knees that can meet his needs. 
 
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 lower leg prosthetics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, additional features or components to a prosthesis may be 
necessary depending on the enrollee's potential functional abilities. Potential functional ability is based on the 
reasonable expectations of the prosthetist, and treating practitioner, considering multiple factors. These factors 
include the enrollee's past history, current condition including the status of the residual limb and the nature of 
the other medical problems and the enrollee's desire to ambulate. In this case, the documentation does not 
support that a microprocessor knee is required. There is no indication the enrollee has previously failed 
treatment with a mechanical knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower leg prosthetics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance 
phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), 
an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase (L5856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued use of a non-invasive ventilator. 
 
You asked the Plan to pre-approve 9 months continued use of a non-invasive ventilator. You say that the 
records provided support the need for the item in dispute.  The Plan denied your request. The Plan says they are 
not able to approve the request after the initial three-month grace period due to lack of medical necessity based 
on the information received.  
 
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 9 months continued use of a non-
invasive ventilator. Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer 
found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease.  The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway 
pressure (BiPAP) machine with average volume assured pressure support (AVAPS) capability and failure of 
such a device has not been documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 months continued use of a non-invasive ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 9 months continued use of a non-invasive 
ventilator.
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 for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 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 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. 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-help/peer services provided on February 21, 2023. 
 
You asked the Plan to pay for self-help/peer services. The Plan denied your request. The Plan says this service 
is not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for  self-help/peer services provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 94761 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 94761 has a status indicator of T on the Physician Fee Schedule. This means that 
procedure code 94761 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 94761 billed for date of service March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on January 3, 
2023. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on January 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9351, S9375, S9379 billed for date of 
service December 17, 2022, to December 23, 2022. 
 
You asked the Plan to pay for procedure codes S9351, S9375, S9379. You say that this should be paid for. 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 codes S9351, S9375, S9379 have a Status Indicator of I on the Physician Fee Schedule. 
This means that these codes are not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure codes S9351, S9375, S9379 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes S9351, S9375, S9379 billed for date of service 
December 17, 2022, to December 23, 2022.
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 meets criteria for inpatient 
LTACH that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care 
Hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from June 16, 2022, to June 18, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that this 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the workup revealed tachycardia, elevated white blood cell (WBC) count, and positive 
blood cultures requiring IV antibiotics. The enrollee required wound care and physical therapy. Based on the 
high-risk status or his bacteremia with potential to worsen quickly without additional supervision, it was 
expected that the enrollee would require at least 2 midnights for this 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services rendered from June 16, 2022, to June 18, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 6, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 6, 2023.