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

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
July 23, 2021. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you had emergency spinal 
surgery and this surgery left you unable to walk. You also say that the surgeon ordered rehabilitation and you 
were unable to be transported by any method but ambulance. The Plan denied your request. The Plan says you 
were not transported to the nearest facility that was able to meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that only mileage to the nearest appropriate facility 
equipped to treat the patient is covered.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for the non-covered ambulance mileage (A0888) provided on July 23, 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. The Plan denied your request. The Plan says you do not have 
complex care needs that require a coordinated team approach. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for gangrene of the lower extremity and had a below the knee 
amputation. Your medical problems are stable. You do not require treatment by multiple therapies in an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental procedures are not covered. 
 
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 requested services are not considered medically reasonable and necessary in this case. The Minuteman 
procedure for interspinous process stabilization is experimental. More research is needed. Our physician 
reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided January 22, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed. 
 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, we have confirmed that code 70450 
has a bundled relationship with code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (70450) provided January 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy with meniscectomy for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation of failure of provider directed treatment 
for 3 months. 
 
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 requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. Additionally, there are no documented mechanical symptoms on the 
exams provided. The x-rays demonstrated degenerative changes of the left knee. 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 to guidelines. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee arthroscopy with meniscectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493 X 2). 
 You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no documentation of the previous injections reporting at least 80% as required 
by the LCD. The Plan states this enrollee reports 20% relief from the initial diagnostic injections; therefore, 
subsequent injections are not medically necessary. 
 
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 physician reviewer 
found the LCD requires 80% pain relief from prior blocks. Therefore, the request is deemed 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 pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493 X 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been 
met. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled 
nursing and/or skilled therapy services on a daily basis.  Although further rehab services would be appropriate 
to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of 
care than a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve doxorubicin hydrochloride liposomal and bevacizumab-
bvzr. 
 
You asked the Plan to pre-approve doxorubicin hydrochloride liposomal and bevacizumab-bvzr. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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] doxorubicin hydrochloride liposomal 
and bevacizumab-bvzr. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the combination of doxorubicin hydrochloride liposomal and bevacizumab-bvzr in not 
considered a standard of care for the treatment of metastatic endometrial cancer.  Use is not supported by major 
drug compenida or the medical literature. Either drug as a single agent is standard. The service is not 
reasonable or medically necessary. The service is unlikely to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of doxorubicin hydrochloride liposomal and bevacizumab-bvzr have not been met. 
Therefore, we decided that the Plan does not have to pre-approve doxorubicin hydrochloride liposomal and 
bevacizumab-bvzr.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that you would like the inpatient 
stay to be approved for coverage. The Plan denied your request. The Plan says the inpatient hospital admission 
is not medically necessary. The Plan also says that the procedure meets the clinical criteria for an outpatient 
procedure. 
 
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 pre-approve an inpatient hospital admission. 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 provider has recommended bronchoscopic lung reduction total lobar 
occlusion for advanced emphysema refractory to optimize medical therapy. The procedure meets the clinical 
criteria for an outpatient procedure. Our reviewer found that there is no specific clinical rationale for inpatient 
level of care services. Our physician reviewer also found that the record does not show that the admitting 
physician reasonably expects that the patient's necessary hospital care will span two 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 an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 9, 2021, to 
March 16, 2021, as billed with Diagnosis Related Group (DRG) 808. 
 
You asked the Plan to pay for inpatient hospital care billed with DRG 808. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 808 is not supported as the principal diagnosis of sepsis, unspecified organism (A41.9) is 
not supported in the medical record. The Plan argues that DRG 809 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient hospital care billed with DRG 808. 
Our reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. Our physician reviewer found that the enrollee presented to the emergency room on March 9, 2021, 
after a fall where she injured her left hip. Her past medical history is significant for chronic obstructive 
pulmonary disease (COPD), coronary artery disease, status post myocardial infarction, type 2 diabetes and 
complex medical history. She slid down from her recliner and had pain in her left hip. Hip X-ray did not show 
evidence of any fracture or deformity. However, tests showed pancytopenia with a white blood cell count that 
was very low, so subsequently she was admitted to intensive care unit for further care. There was no clinical or 
laboratory evidence of sepsis. The review has determined that the medical records did not support the billing of 
sepsis, unspecified organism (A41.9.) 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care billed with DRG 808 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from March 9, 2021, to 
March 16, 2021, as billed with Diagnosis Related Group (DRG) 808.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, and 
83970) provided on September 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim is denied for not meeting coding standards. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation submitted showed that the laboratory tests reported were related to treatment of ESRD 
since end-stage renal disease was indicated as a reason for the laboratory tests, and a separate professional visit 
unrelated to ESRD was not indicated in the medical record. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (CPT code(s): 82728, 83540, and 83970) provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the power operated vehicle. You say that you cannot walk outside without 
help. This is the reason you request the power wheelchair because you want to use it for outside needs and 
shopping The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested 
power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 operated vehicle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does indicate the enrollee has a mobility deficit. The 
documentation does not support that the mobility deficit impairs MRADLs in the home and this mobility 
limitation is not ameliorated by a walker, cane, manual wheelchair. The enrollee is able to ambulate in the 
home independently with a cane. She uses a walker outdoors. While the enrollee may have the cognition to 
safely operate the power scooter the documentation does not reveal that the requested device will be able to be 
brought into the home as there are stairs to access her apartment. The documentation does not support that the 
POV will significantly improve the patients ability to participate in MRADLs and the enrollee will use it in the 
home. The documentation does not reveal that the requested K0800 motorized scooter is 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 the power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to 
and including 300 pounds (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid for the enrollee.  
 
 
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital stay beginning April 25, 2022. 
 
You asked the Plan to pre-approve the inpatient hospital stay. You say that the enrollee has a history of blood 
clots which is the main reason for the inpatient stay. The Plan denied your request. The Plan says the inpatient 
hospital stay is not medically reasonable and necessary. 
 
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 pre-approve the inpatient hospital stay. 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 record does not show that the admitting physician reasonably expected that the 
patient's necessary hospital care would span two 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 the inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital stay beginning April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says Prednisone is only 
covered under the medical benefit if you have had an organ transplant. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.  
 
 
 Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) provided on December 13, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that this is supported in the records. The Plan denied 
your request. The Plan says the requirements for coverage have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy (90832) provided on December 13, 
2021.