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

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel provided 
to the enrollee on February 11, 2021. 
 
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 Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not indicate how the test results will assist in managing the enrollee's condition. The review has determined that the services at issue in this case are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the cardiovascular screening/risk assessment panel provided to the enrollee on February 11, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair (PWC) with single 
power option (K0856) and additional features. 
 
You asked the Plan to pre-approve a group three power wheelchair (PWC) with single power option (K0856) 
and additional features.. You say that the items are medically necessary. The Plan denied your request. The 
Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria in the Medicare Rules section must be met 
for coverage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group three power wheelchair (PWC) 
with single power option (K0856) and additional features. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that the patient uses a ventilator 
attached to a wheelchair, is at high risk for development of a pressure ulcer. There is no history of current or 
prior pressure ulcers of skin flap surgery.  There is no evidence of the use of intermittent catheterization. The 
documentation is not consistent as the 3/9/22 physician document with conflicting information advises the 
patient to continue to walk with a walker.  The physician documentation does not indicate objective evidence 
of spasticity on a BLE physical exam that needs a power seating system for management.  The power elevating 
leg rests were requested due to edema per an appeal from the vendor on 4/25/22 but the physician 
documentation indicates no history of edema on review of systems or on objective exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group three power wheelchair (PWC) with single power option (K0856) and 
additional features. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group three power wheelchair (PWC) with single power option (K0856) and additional features.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional x-ray service provided to the enrollee on 
September 6, 2021. 
 
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 this is a duplicate claim. 
 
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 find that CPT code 71045 is not supported in the medical record. Specifically, there is no indication that 
multiple x-ray services were rendered in this case. 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 x-ray service provided to the enrollee on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator. 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically 
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 non-invasive home ventilator. Our 
reviewer says that the documentation does not support that the requested item is medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease. The 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. Therefore, the enrollee does not 
meet criteria for the requested device. 
 
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 non-invasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-invasive home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services. 
 
You asked the Plan to pre-approve ambulance services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no medical need for you to require an ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that ambulance services are not medically reasonable and necessary. Your symptoms do not meet prudent 
layperson criteria for emergency care. You were being transferred from the hospital in stable condition. The 
documentation does not support that other means of transport (such as stretcher van) are contraindicated for 
you. You do not need the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. There was no evidence on the recent notes to suggest 
medical supervision or treatment was needed during transport. Our physician reviewer found that your 
condition does not meet Medicare criteria for ambulance services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission from April 6, 2022 to April 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show any abnormal vital signs, change in mental status, 
failure of outpatient treatment, severe infection of the leg, rapidly progressing infection, poor immune system, 
blood stream infection, gas in the tissue around the infection, severe mouth infection, need for surgery, or 
severe pain. 
 
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 enrollee was stable and responding to initial treatment. There was insufficient 
support made in the documentation from the emergency department that the patient's care needs including 
antibiotics, pain treatment, and followup on culture results would require hospital services that would likely 
cross 2 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 inpatient admission from April 6, 2022 to April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain affects her quality of 
life. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
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 requested services.  Our physician 
reviewer found that the requested Intracept procedure is experimental. More research is needed to show safety 
and efficacy. Therefore, the request is not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. All medically necessary care is being provided in the current acute care facility. 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 health plan. The health plan has approved ongoing care in the current acute care facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided to the enrollee on 
August 10, 2021. 
 
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 separate payment is never made for routinely bundled services and supplies. 
 
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 find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services (99100) provided to the enrollee on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography, heart, 
coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing 
(75574). 
 
You asked the Plan to pre-approve a CT angiography. You say that the enrollee has a history of bypass, 
currently having ongoing chest pain, and their stress test was abnormal. You also say that a CT of the coronary 
arteries with heart flow needs to be done to determine the reason. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Multidetector computed tomography (MDCT) 
angiography of the chest for cardiac assessment will be considered medically reasonable and necessary for the 
signs or symptoms of disease listed in the Medicare rules section above.  
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 CT angiography. Our reviewer says 
that a CT angiography is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has a history of previous coronary artery bypass and has anginal symptoms. Our 
reviewer found that stress test has documented a reversible defect and cardiac catheterization is considered.    
The elements of the coverage criteria are not satisfied.  The requested service cannot be 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 a CT angiography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic (CT) angiography, heart, coronary arteries and bypass grafts 
(when present), with contrast material, including 3D image postprocessing (75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation device (HFCWO). You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for coverage. 
 
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 high frequency chest wall oscillation 
device (HFCWO). Our reviewer says that the service is not medically necessary. Our physician reviewer found 
that it is unclear whether the patient still has bronchiectasis and there is no evidence that other airway clearance 
measures have been tried and failed, such as conventional chest physiotherapy or a flutter valve with postural 
drainage. 
 
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 high frequency chest wall oscillation device (HFCWO) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total shoulder arthroplasty with biceps tenodesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left shoulder primary 
osteoarthritis with bilateral shoulder pain. There is no detailed documentation of a trial and failure of recent, 
reasonable, and comprehensive less-invasive conservative care measures. Reasonable deltoid function and 
motion (close to 90 degrees to support prosthetic function) is not fully evident. Additionally, there is no 
imaging evidence of a large/massive rotator cuff tear. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested left total shoulder arthroplasty with tenodesis of the biceps, in this case, is 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total shoulder arthroplasty with biceps tenodesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
December 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network 
provider on December 6, 2021.
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 cannot adequately recover in a less 
intensive setting. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage. 
 
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 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. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
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.