Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA disc intradiscal therapy procedure (0627T). 
 
You asked the Plan to pre-approve VIA disc intradiscal therapy procedure. You say that this procedure is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is 
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 VIA disc intradiscal therapy procedure. 
Our reviewer says that the requested VIA disc intradiscal therapy procedure is not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. The reviewer found that further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. The reviewer found that there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the reviewer found that the requested VIA Disc intradiscal therapy procedure 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 VIA disc intradiscal therapy procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a VIA disc intradiscal therapy procedure (0627T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the sacroiliac joint 
(64625). 
 
You asked the Plan to pre-approve an RFA of the sacroiliac joint. You say that you had this same procedure in 
May 2022, which gave you nine months of complete relief. You also say that the intense pain you are 
experiencing now is the same pain that you experienced prior to your first sacroiliac joint ablation. The Plan 
denied your request. The Plan says ablation procedures are not supported by research to treat pain in the joint 
that connects the pelvis to the tailbone (sacroiliac pain). 
 
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 an RFA of the sacroiliac joint. Our 
reviewer says that the requested RFA of the sacroiliac joint is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
procedure because of the wide variation in efficacy reported in the peer reviewed literature. 
 
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 RFA of the sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation (RFA) of the sacroiliac joint (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If this enrollee does have chronic carbon dioxide (CO2) retention, they may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatments (98941), extraspinal 
chiropractic manipulative treatments (98943), office visits (99213), and the electrical stimulation therapy 
(97014) provided from January 8, 2021, through November 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that they did not receive enough information 
to consider the charges submitted. 
 
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 stated that they did not receive enough information to 
make a decision on the submitted charges for the services provided in this case. However, sufficient medical 
records were provided to their organization to verify the services performed. The Plan has not substantiated 
their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the 
chiropractic manipulative treatments (98941), extraspinal chiropractic manipulative treatments (98943), office 
visits (99213), and the electrical stimulation therapy (97014) provided from January 8, 2021, through 
November 18, 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 CardioMEMs Heart Failure (HF) system. 
 
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 CardioMEMs system was approved 
by the Food and Drug Administration (FDA) in 2019. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
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 an LTACH can render services that will 
improve the member's condition and avoid unnecessary hospital readmissions. The Plan denied your request. 
The Plan says the member does not meet the requirements for an LTACH admission. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The requested 
service cannot be recommended as the elements of the coverage rules 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 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 laboratory services rendered on November 18, 2021. 
 
You asked the Plan to pay for these services. You say that the claim was billed correctly. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier.  
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. The file does not contain a UB04 claim form with the Dex-Z code. 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 pay for the laboratory services rendered on November 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (86677) provided on June 8, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim is denied as the 
criteria for this service are not met. 
 
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 a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for laboratory services (86677) provided on 
June 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the therapy services (97530) provided on November 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that more than four 
interventions during the same treatment session are not considered a reasonable charge. 
 
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 argues that more than four interventions during the same treatment 
session are not considered a reasonable charge. However, the Plan has not provided a Medicare rule showing 
that the services in this case are not payable or covered. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the therapy services (97530) 
provided on November 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
December 5, 2022. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says this provider is 
not payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. The billing provider is not eligible for payment for OTP services. 
Individual providers are not payable for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the OTP services have not been met. Therefore, we decided that the Plan does not have to 
pay for the opioid treatment program (OTP) services provided on December 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nasopharyngoscopy, surgical, with dilation of 
eustachian tube (balloon dilation). 
 
You asked the Plan to pre-approve a nasopharyngoscopy, surgical, with dilation of eustachian tube (balloon 
dilation). You say that you have right sided eustachian tube dysfunction and you have been struggling with 
hearing on the right side as well as popping and cracking. The Plan denied your request. The Plan says the 
requested nasopharyngoscopy, surgical, with dilation of eustachian tube (balloon dilation) is 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 a nasopharyngoscopy, surgical, with 
dilation of eustachian tube (balloon dilation). Our reviewer says that the requested nasopharyngoscopy, surgical, with dilation of eustachian tube (balloon dilation) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records provided in this case do not document 
that audiometry has been recently performed or that other causes of your symptoms, such as a mass lesion, 
have been ruled out. Such testing is generally recognized as standard practice for the evaluation of eustachian 
tube dysfunction before surgery is performed.  
 
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 nasopharyngoscopy, surgical, with dilation of eustachian tube (balloon 
dilation) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
nasopharyngoscopy, surgical, with dilation of eustachian tube (balloon dilation).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent testing (87798) provided on December 6, 
2022. 
 
You asked the Plan to pay for infectious agent testing 87798. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this code is not covered because the Plan already covered 
code 87631 and respiratory pathogen panel testing must be billed with a single unit of service. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panel tests should be billed 
as a single unit of service.  
 
We looked at the file and Medicare rules. The Plan already paid for this respiratory pathogen panel testing 
under code 87631, an additional individual component code is not covered. Based on this information, we 
decided that Medicare rules for coverage of infectious agent testing 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for infectious agent testing (87798) provided on December 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on July 20, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that you do not agree with the denial of this service. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chest x-ray provided 
on July 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) imaging with C11 
choline. 
 
You asked the Plan to pre-approve the C11 choline PET imaging. You say that this imaging is needed to ensure 
that there is no recurrence of disease. The Plan denied your request. The Plan says the enrollee has had several 
subsequent PET scans since completing treatment. This request exceeds the medical need. 
 
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 C11 choline PET imaging. Our 
reviewer says that the requested PET imaging is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 75-year-old male with a history of Gleason's grade 4+5 
prostate cancer, originally diagnosed in 2009, with subsequent radical prostatectomy, radiation, extended bilateral pelvic lymphadenopathy, Lupron injections, and salvage proton radiation treatment. The enrollee has 
had an undetectable prostate-specific antigen (PSA) since September 2017. He has also had 6 negative C11-
choline PET scans for surveillance since that time. Most recent PSA was <0.1 ng/mL on November 9, 2022.  
 
C11 choline PET scan is not medically reasonable and necessary in this case. Routine surveillance imaging 
following treatment of prostate cancer is not medically necessary. Restaging imaging is medically necessary 
when there are signs or symptoms of recurrent disease, including a rising PSA level. The medical records do 
not indicate that there are signs or symptoms of recurrent prostate cancer. The PSA has been undetectable for 
greater than 5 years.  
 
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 C11 choline PET imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve positron emission tomography (PET) imaging with C11 choline.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 15-21 classes (G0482) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-21 classes. You say that this claim should be 
paid. The Plan denied your request. The Plan says that only 9 classes of drugs were tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is definitive drug testing of 22 or more drug classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the drugs tested 
and confirmed that 15-21 classes of drugs were tested. Based on this information, we decided that Medicare 
rules for coverage of the definitive drug testing of 15-21 classes have been met. Therefore, we decided that the 
Plan has to pay for the definitive drug testing of 15-21 classes (G0482) provided on November 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee has limited mobility 
and minimal muscle tone. The requested bed is medically necessary. The Plan denied your request. The Plan 
says the requested bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).