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

 
We decided that the Plan does not have to pre-approve transthoracic echocardiogram (TTE). 
 You asked the Plan to pre-approve TTE. You say that TTE is medically necessary. The Plan denied your 
request. The Plan says TTE does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 TTE. Our reviewer says that TTE is not 
medically necessary. Our physician reviewer found at issue is the medical necessity of a repeat TTE, in the 
absence of any apparent significant change in the enrollees clinical condition. Clinical guidelines do not 
support repeating a TTE with no intervening change in clinical status or physical findings. In summary, there is 
no supportive evidence for the medical necessity of repeat TTE in this enrollees clinical management. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TTE.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the enrollee is at risk for lung disease. The Plan 
denied your request. The Plan says the enrollee does not have bronchiectasis, cystic fibrosis, or neuromuscular 
disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a HFCWOD. Our physician reviewer found the records do not document that the enrollee has bronchiectasis, cystic fibrosis, or a neuromuscular disease as required by 
Medicare rules. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve psychotherapy. You say that your reason for making this out-of-network 
request to find a faith-based counselor who shares your religious views is because you would feel more 
comfortable with a faith-based counselor and feel this denial is impeding on your religious rights. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 
psychotherapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this equipment is medically reasonable 
and necessary. The Plan denied your request. The Plan says Medicare does not cover ventilators used in this 
way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. Based 
on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery for a vertiflex superion device (a metal device 
placed in between the bones of the lower back) (22869). 
 
You asked the Plan to pre-approve surgery for a vertiflex superion device (a metal device placed in between the 
bones of the lower back). You say that this treatment is considered safe and effective, as supported by its 
clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with 
numerous peer-reviewed studies. The Plan denied your request. The Plan says this service is not covered under 
the member's benefit plan. 
 
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 surgery for a vertiflex superion device 
(a metal device placed in between the bones of the lower back). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Food and Drug Administration (FDA) contraindications include spinal instability, scoliosis, obesity, 
and osteoporosis, and have not been adequately address in the medical records. Our physician reviewer also 
found that there is no formal lumbar magnetic resonance imaging (MRI) provided for the review, and no 
compelling rational presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery for a vertiflex superion device (a metal device placed in between the 
bones of the lower back) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
surgery for a vertiflex superion device (a metal device placed in between the bones of the lower back) (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is 
considered 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 is requires daily physician 
management with close medical monitoring and cannot adequately be cared for in their current condition in a 
skilled nursing facility. You say that the enrollee needs aggressive physical and occupational therapy to regain 
maximum function to have a safe discharge. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollees needs can be met in current hospital setting. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
or the skilled nursing facility. The requested treatments are not medically necessary at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special mattress and a semi-electric hospital bed 
(E1399, E0261). 
 
You asked the Plan to pre-approve a special mattress and a semi-electric hospital bed. You say that the enrollee 
no longer needs the Air Fluidized therapy and is really wanting to transition back down. The Plan denied your 
request. The Plan says the enrollee does not require a special mattress as the semi-electric hospital bed is not 
needed as his wound has healed. Based on the additional information available, the request does not meet the 
Medicare or health plan coverage criteria. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 special mattress and a semi-electric 
hospital bed. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollees condition does not require positioning of the body in ways 
not feasible in an ordinary bed; or special attachments that cannot be fixed and used on an ordinary bed. There 
is no evidence of an immediate need for changes in body position. The criteria for the semi-electric hospital 
bed have not been met and therefore the special mattress for the bed is also not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a special mattress and a semi-electric hospital bed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a special mattress and a semi-electric hospital 
bed (E1399, E0261).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on May 3, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the clinical notes support medical necessity. 
The Plan denied your request. The Plan says the code was billed with an inappropriate place of service. 
 
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 99335 was billed with a place of service code 12. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the evaluation and management services provided on May 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0999) provided on May 29, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you feel you should not be held responsible 
for this bill because the paramedics advised you did not need to go to the hospital. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2022. The record shows that your vitals 
were checked, found to be within the normal limits, and you did not wish to be transported to the hospital by 
ambulance. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor 
the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the 
ambulance service (A0999) provided on May 29, 2022.
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 has complex wound care 
which requires an LTACH. You say that the enrollee would need close observation and a support surface for 
wound healing. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, 
and the enrollee can continue to receive their care in another setting. 
 
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 the enrollee is currently receiving care. The health plan has approved ongoing care 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of allogeneic cellular/tissue-based product 
(Via Disc procedure). 
 
You asked the Plan to pre-approve Via Disc procedure. You say that the enrollee has opted for Via Disc 
treatment. The Plan denied your request. The Plan says this procedure is considered 
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 Via Disc procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this treatment is considered experimental and investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via Disc procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection of allogeneic cellular/tissue-based product (Via Disc procedure).
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 a home ventilator is to be used for the 
treatment of obesity hypoventilation syndrome (OHS). The Plan denied your request. The Plan says the request 
for a home mechanical ventilator set in AVAPS mode with or without Auto-EPAP (AE) that could be delivered 
by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently 
hospitalized. ABGs showed mild CO2 retention but were all done while intubated on a ventilator. There is no 
ABG done while stable to document chronic CO2 retention. There is no diagnosis for which Medicare covers a 
home ventilator: COPD, thoracic restrictive disease, certain neuromuscular diseases. If the enrollee does have 
chronic CO2 retention, she may benefit from BiPAP during sleep as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be paid. 
The Plan denied your request. The Plan says prior authorization was not obtained before the service was 
rendered to the enrollee. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 office visit (99214) provided on June 3, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for neuromonitoring and specialist office visit 
provided on March 17, 2022. 
 
You asked the Plan to waive the copayments for neuromonitoring and specialist office visit. You say that you 
do not understand why and what you are paying for. 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 $225 
copayment for neuromonitoring and $25 copayment for physician/practitioner service.  
 
You have been asked to pay $117.53, which is less than the $225 copayment for outpatient hospital service and 
$25 copayment for specialist office visit. This item/service falls within the outpatient hospital services and physician/practitioner services, including doctors office visits benefit categories. 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. Therefore, we decided that the Plan does not have 
to waive the copayments for neuromonitoring and specialist office visit provided on March 17, 2022.
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 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 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 enrollee was admitted to the hospital for surgical management of T12 and L1 
fractures after a fall. He is now medically stable with no complex nursing or rehabilitation needs. He does 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.