Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE testing. You say that the enrollee has diagnoses of chronic atrial 
fibrillation, non-ischemic cardiomyopathy, and hypertension. The Plan denied your request. The Plan says 
repeat testing sooner than 1 year from the previous study is not supported. 
 
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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a transthoracic echocardiogram in January 2023, which is only supported once 
per year in the absence of change in clinical status or new signs/symptoms. The documentation does not 
support the need for a repeat echocardiogram sooner than 1 year.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) testing.
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's current condition requires 
an LTACH level of care. 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 appears to still be unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended. 
 
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 urine polymerase chain reaction (PCR) testing provided on 
June 23, 2023. 
 
You asked the Plan to pay for urine PCR testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the services at issue 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 urine PCR testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by 
a urine culture and susceptibility studies. There is lack of support in the medical literature for the clinical utility 
of large multiplex PCR urinary tract infection panel tests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine polymerase chain reaction (PCR) testing provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183). 
 
 
 
 You asked the Plan to pre-approve HBO therapy. You say that the enrollee has arterial insufficiency and failed 
a recent revascularization attempt. Laceration will continue without aggressive conservative management, as it 
could lead to infection in bone and loss of limb. The Plan denied your request. The Plan says you have had a 
sore on your left leg for some time. It is noted to be due to low blood flow to your legs. This treatment is not 
covered for chronic sores. 
 
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 HBO therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has ulceration of non-pressure chronic ulcer of the ankle in 
the setting of chronic arterial insufficiency. The noted condition is not one for which coverage is available 
under the rules. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183).
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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, however, this can be provided in a lower 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
March 15, 2023, to March 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not think that 
the enrollee should be liable. 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 $240 
copayment for inpatient hospital care. 
 
You have been asked to pay a $240 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. 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. The enrollee has been asked to pay a total of $1440 for the inpatient hospital stay ($240 
copayment x 6 days = $1440). Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided on March 15, 2023, to March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR). 
 
You asked the Plan to pre-approve TAVR. 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 follows Medicare rules. Medicare rules say that TAVR is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve TAVR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found at this time the requested TAVR would not 
be considered medically necessary in this enrollee's clinical management based on the submitted 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter aortic valve replacement (TAVR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399) and a bed 
accessory: board, table, or support device, any type (E0315). 
 
You asked the Plan to pre-approve the seat lift mechanism and bed board. You say that the medical records 
provided support the necessity of the services in dispute.  The Plan denied your request. The Plan says the 
records do not support the enrollee meets the criteria for a seat lift. A bed board is not covered as not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. The rules say that for equipment to be covered, it must primarily 
serve a medical purpose.   
 
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 seat lift mechanism and bed board. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided records in this case document polyarthropathy or 
polyathritis of multiple sites. The records in this case document an order for the seat lift but medical visit notes 
do not document the seat lift is included in the treating practitioner's course of treatment or that the seat lift is 
likely to: (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's 
condition. The records do not document the enrollee is completely incapable of standing from a chair in the 
home or that the enrollee has the ability to ambulate though the enrollee does require the use of a walker. The 
requested bed board/table does not serve a purpose that is primarily medical in nature. This item is available to 
the general public and would be helpful even to those who are not sick or injured. 
 
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 seat lift mechanism and bed board have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399) and a bed accessory: board, 
table, or support device, any type (E0315).
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's current condition requires an IRF level 
of care. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements 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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy services (92507) provided from February 14, 
2023, to February 28, 2023. 
 
You asked the Plan to pay for speech therapy services. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 92507. Any codes which are not listed are considered not medically necessary for 
code 92507. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of speech therapy services have not been met. Specifically, these claims were submitted with a 
diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for speech therapy services (92507) provided from 
February 14, 2023, to February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve use of an advanced pneumatic compression device (E0652) with 
appliances. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that the enrollee's basic pump 
failed. The Plan denied your request. The Plan says that the records do not show that lymphedema has extended 
into the chest, trunk, or abdomen. Additionally, the enrollee did well with a basic pump. 
 
The Plan follows Medicare rules. Medicare rules state that an advanced pneumatic compression device may be 
covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pneumatic compression device. Our 
reviewer says that the enrollee meets criteria for this pneumatic compression device. Our physician reviewer 
found the enrollee has a clear diagnosis of severe lymphedema secondary to malignancy who has failed 
conservative therapy with basic pump and compression wear. Thus, pneumatic compression device is 
medically necessary and meets criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device have been met. Therefore, we decided that the 
Plan has to pre-approve use of an advanced pneumatic compression device (E0652) with appliances.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 reader. You say that the enrollee has type 2 diabetes. 
The Plan denied your request. The Plan says the medical records received were reviewed and the medication 
records do not show any insulin use, or any documentation of low blood glucose levels.  
 
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 Freestyle Libre 2 reader. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage for CGM 
require insulin or low blood glucose sugar. Although the enrollee seems to have been prescribed insulin in 
February 2023, they are not taking this in September and are not having low blood glucose sugar or on 
medications that cause low blood glucose sugar so coverage criteria 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 the Freestyle Libre 2 reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 2 reader.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee and a foot addition (L5828, L5845, L5848, 
L5856, L5988) for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve a microprocessor knee and a foot addition. You say that the requested items 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested items 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that that a lower limb prosthesis is covered when the 
enrollee: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 microprocessor knee and a foot addition. Our reviewer says that the requested items are medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record goes above and beyond in satisfying Medicare policy by 
demonstrating that the enrollee has K3 functional-level potential and has specific needs for the requested 
components. The broad, inclusive K3-criteria specified in the Medicare rules merely describe the average 
Medicare enrollee who lives independently at home and in the community, which this enrollee will certainly be 
able to do if equipped with the right prosthesis matching their functional level. Medicares policy recognizes 
that microprocessor knees (as well as the standard addition codes that go with K3 feet, like L5988) are part of 
the basic standard of care for all community above-knee amputee ambulators, given that the evidence of their 
benefits and superiority to less sophisticated alternatives is so well proven and long-standing.  In the case of the 
enrollee and all comparable K3 ambulators, lesser devices simply would not meet their functional needs and 
would amount to substandard care. There is no doubt that original Medicare would cover the entirety of the 
requested prosthesis for this K3-level enrollee. 
 
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 microprocessor knee and a foot addition have been met. Therefore, we 
decided that the Plan has to pre-approve a microprocessor knee and a foot addition (L5828, L5845, L5848, 
L5856, L5988) for a lower-limb prosthesis.  
 
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 pay for code 99291 billed for date of service May 29, 2023. 
 
You asked the Plan to pay for code 99291. You say that this patient was covered by the Plan on this date of 
service. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 31645 
provided on May 29, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99291 billed for date of service 
May 29, 2023.