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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 1, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when this 
response was requested, you were being cared for by an inexperienced person who did not have the knowledge 
of administering food for the diabetic situation which you were suffering from. You also say that if you were 
carried to the hospital for treatment in the emergency room, the expense would have far exceeded the $346.00 
which was ordered by a simple mistake. The Plan denied your request. The Plan says you did not want to be 
transported to the hospital. 
 
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 November 1, 2021. 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 response and treatment with no 
transport (A0998) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L9900). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L9900).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the retainer crown (D6750). 
 
You asked the Plan to pre-approve the retainer crown. You say that this service is necessary. The Plan denied 
your request. The Plan says that you have already used the maximum for prosthodontic services. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to show that you have 
already used your $1,500 benefit allowance for the 2022 Plan year. Based on the documentation provided, it 
seems that the total sum of the requested dental treatment including services not at issue in this case may 
exceed $1,500; however, payment is a retrospective issue that cannot be reviewed in full until services are 
provided and a bill is produced. Please note that pre-approval of services does not guarantee full payment. 
There is no indication that the service in this case is not medically necessary. Therefore, we decided that the 
Plan has to pre-approve the retainer crown (D6750).  
 
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 the stationary compressed gas oxygen (E0424). 
 
You asked the Plan to pre-approve the stationary compressed gas oxygen. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of cluster headaches for this 
member. 
 
The Plan must follow Medicare rules. Medicare rules say that stationary compressed gas oxygen is only 
covered for the treatment of cluster headaches. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the stationary compressed gas oxygen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the stationary compressed gas oxygen (E0424).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face-down positioning device. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says these devices are non-covered because they do not fall within a Medicare benefit 
category. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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. Therefore, we 
decided that the Plan does not have to pre-approve a face-down positioning device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal system addition (L5910). 
 
You asked the Plan to pre-approve an endoskeletal system addition. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the documentation does not show that L5910 is 
damaged beyond repair and cannot be re-used. While notes from the prosthetist (vendor) state replacement is 
needed for L5910, the physician office visit notes do not corroborate the vendor's notes showing need to 
replace L5910. 
 
The Plan must follow Medicare rules. The rules say payment may be made for the replacement of a prosthetic 
device that is an artificial limb, or replacement part of a device if the ordering physician determines that the 
replacement device or part is necessary because of any of the following:  
1. A change in the physiological condition of the patient;  
2. An irreparable change in the condition of the device, or in a part of the device; or  
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an endoskeletal system addition have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal system addition (L5910).
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 requires three hours of therapy a day 
provided by a multidisciplinary team. The Plan denied your request. The Plan says the enrollee does not meet 
all the required 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 the enrollee was admitted for myocardial infarction and coronary artery bypass 
grafting. Medical problems are currently stable and there are no complex nursing or rehabilitation needs. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hyqvia injection (J1575), non-insulin infusion catheter 
supplies (A4221), and drug infusion pump supplies (K0552), provided on July 21, 2021. 
 
You asked the Plan to pay for the Hyqvia injection, non-insulin infusion catheter supplies, and drug infusion 
pump supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says 
there is no proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the Hyqvia injection (J1575), non-insulin infusion catheter supplies (A4221), and drug infusion pump 
supplies (K0552), provided on July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the records confirm twenty-two (22) out of twenty-four (24) one-way transportation 
trips have been used/exhausted for the 2022 calendar year. Additional routine transportation services are not 
covered beyond the benefit allowance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the temporary catheter insertion (51702) provided on April 14, 2021. 
 
You asked the Plan to pay for the temporary catheter insertion (51702). You say that CPT code 51702 was 
billed with modifier 59 to indicate it was a distinct procedure. You say that the documentation should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says that column two 
procedures are not eligible for reimbursement when billed with an associated column one procedure, when the 
use of a modifier is not appropriate. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit documentation showing a column 1 code was billed on 
the same date of service for CPT code 51702 to be considered inclusive. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the temporary catheter insertion (51702) 
provided on April 14, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is 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 Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition. 
 
 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric hospitalization. You say that the enrollee is 
struggling and is not stable for discharge. You say that the denial is adding to the enrollee's depression and 
anxiety. The Plan denied your request. The Plan says the enrollee is showing that they are feeling okay. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continued inpatient psychiatric 
hospitalization. Our reviewer says that a continued inpatient psychiatric hospitalization is not medically 
necessary. Our physician reviewer found it is not expected this enrollee would improve in a reasonable period 
of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or 
visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. 
 
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 continued inpatient psychiatric hospitalization have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization to be 
provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair (E1399). 
 
You asked the Plan to pre-approve a lift chair. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not medical in nature and is regularly and primarily used by persons 
who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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. Therefore, we 
decided that the Plan does not have to pre-approve a lift chair (E1399).
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 go home because it is not safe for 
him. The Plan denied your request. The Plan says a lower level of care is more appropriate. 
 
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 for cellulitis of the lower extremity. Medical problems are 
stable and there are no complex nursing or rehabilitation needs.  
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for an IRF admission. The 
Plan denied your request. The Plan says criteria for admission to the IRF  setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. 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.
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 an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says medical records do not support the ability to tolerate an 
intensive rehabilitation therapy program. 
 
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 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx testing provided on December 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was ordered with the intent to use the 
results to inform treatment decisions. The Plan denied your request. The Plan says there is a lack of clinical 
validity and clinical utility when used in testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the supplier must furnish to the carrier sufficient 
information to determine whether payment is due. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to determine if 
Medicare rules for coverage have been met. Therefore, we decided that the Plan does not have to pay for the 
DecisionDx testing provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral breast augmentation with implants for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary due to insufficient information about a psychological 
assessment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has gender dysphoria. The record indicates that the enrollee has 
received counseling but only has a single psychiatric evaluation that discusses vaginoplasty. The record 
provided is insufficient to establish the medical necessity, as defined by Medicare rules, a this time. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 pre-approve bilateral breast augmentation with implants for the enrollee.