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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to care for themselves and has 
not made any progress. The Plan denied your request. The Plan says admission to the SNF is not medically 
necessary.  
 
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 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostatic arterial embolization (37242). 
 
You asked the Plan to pre-approve a prostatic arterial embolization. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 a prostatic arterial embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has benign prostatic hyperplasia (BPH)-related symptoms and prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Only 
very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do 
not recommend this procedure outside of a clinical trial setting due to the heterogeneity in the available 
literature and safety concerns. 
 
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 prostatic arterial embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a prostatic arterial embolization (37242).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this is supported in the 
records. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77427) provided on November 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 77427 is "Radiation treatment management, 5 
treatments". 
 
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 the services. Our reviewer says that the use of code 77427 is 
not supported by the records provided. Our reviewer found that the documentation does not support the break 
in therapy. The documentation does not follow CPT guidelines.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (77427) provided on November 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing this decision. The Plan denied 
your request. The Plan says based on Medicare guidelines, the SNF services requested 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), 
electronic connection (E2311), power seat elevation system (E2300), and calf pads (K0108).  
You asked the Plan to pre-approve the power wheelchair accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the seat elevator does not primarily serve a medical 
purpose and is statutorily non-covered. Calf pads are unbundled from the power wheelchair base K0861 and 
cannot be requested separately. There is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the power wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have adequate strength to manage standard power drive controls.  
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), electronic 
connection (E2311), power seat elevation system (E2300), and calf pads (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollees health problem. 
 
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 a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of a stroke, PFO, exposure to antipsychotics with long 
standing history of action tremor worsening in recent years. Exam notes postural tremor consistent with 
essential tremor. He also has right sided parkinsonian features in form of a resting tremor. Etiology felt to be 
drug induced vs degenerative. Less likely to be essential tremor but will monitor as the essential tremor is 
addressed. Treatment options for the essential tremor include medications, discussion of CalaTrio device which 
the enrollee will try. An addendum states the enrollees ADLs are affected by the tremor. There is insufficient 
evidence in the literature that this device is effective for the enrollee's condition. The requested K1018 is not 
the standard of care for this enrollee's tremor according to current guidelines.  
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018, K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine injection provided on February 2, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says payment for Bupivacaine is included in the global surgery payment for 
a procedure provided on the same date.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure denoted by code 27096 provided on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the services at issue have not been met. Therefore, 
we decided that the Plan does not have to pay for Bupivacaine injection provided on February 2, 2023.
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 you have become lightheaded and are fainting. The 
Plan denied your request. The Plan says you do 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 that the clinical documentation shows you have active medical comorbidities; 
however, no complex functional impairments have been specified. Thus, the complexity of your documented 
nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The clinical documentation shows that you require ongoing 
physical therapy and occupational therapy but does not show that you would require or tolerate an intensive 
rehabilitation regimen.  
 
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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a home ventilator for three (3) months. We decided that the Plan 
does not have to pre-approve continued use of a home ventilator after 3 months.  
 You asked the Plan to pre-approve a home ventilator (E0466). You say that the enrollee has been using the 
ventilator for several years at home and needs to continue using the home ventilator. The Plan says that the 
records show that the NIV is going to be used only in a CPAP/Bi-level PAP mode. 
 
We decided that the Plan has to pre-approve a home ventilator for three (3) months.  
 
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 partially medically necessary. Our physician reviewer found the enrollee has COPD and 
severe obesity and has been using a home ventilator since 2021. A compliance download covering May 10 to 
June 8, 2023, showed 47% of days with at least 4 hours of usage, but previously, April 17 to May 16, usage 
was 90%. The current device should be approved for 3 months to allow time for transition to BiPAP. 
Therefore, we decided that the Plan has to pre-approve a home ventilator for three (3) months.  
 
We also decided that the Plan does not have to pre-approve continued use of a home ventilator after 3 
months. 
 
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 there is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. It appears this enrollees respiratory support needs could be met 
with BiPAP with AVAPS.  Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. Therefore, we decided that the Plan does not have to pre-approve continued use of a 
home ventilator after 3 months. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee continues to need close 
monitoring of their complex medical needs. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for admission to the 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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 64447 rendered on 
February 13, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
two separate blocks for nerve to vastus intermedius and genicular nerve. For this procedure, only one unit is 
supported. One unit of service is allowed daily for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 64447 rendered on February 13, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for home health (HH) services provided from October 10, 2022, to 
November 7, 2022. 
 
You asked the Plan to pay for HH services. You say that these services were reported appropriately. The Plan 
denied your request. The Plan says that the FIPS code reported on this claim is incomplete, as it should be 8500 
and not just 85. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that providers must report services correctly. To ensure payment adjustments for 
home health services provided in a rural area or rural county are applied accurately, the home health agency 
(HHA) must report value code 85 to report the Federal Information Processing Standards (FIPS) state and 
county code of where the services were received. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans assertion that the correct FIPS code is 8500 is incorrect 
in this case and is not supported with the evidence provided. Medicare rules state that reporting value code 85 
is appropriate, and all FIPS codes are an additional 5 digits which are separate from the value code. The claim 
submitted in this case shows that FIPS code 28071 was reported under value code 85, which is accurate and 
appropriate for these services. Therefore, we decided that the Plan has to pay for home health (HH) services 
provided from October 10, 2022, to November 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for treatment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a referral for treatment to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a referral for treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 5, 2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that this should be paid for. 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 5, 2022.