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

 
We decided that the Plan does not have to pay for lab services provided on August 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee is in need of ordered equipment to 
prevent hospitalization. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in intelligent volume-assured pressure support (IVAPS) mode with auto-expiratory positive 
airway pressure (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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was recently hospitalized with a COPD exacerbation, and arterial blood gas (ABG) 
was consistent with acute on chronic hypercarbic respiratory failure. There are no pulmonary function tests to 
assess the severity of the COPD, and no ABG done while stable to document chronic CO2 retention. If this 
enrollee does have severe COPD with chronic carbon dioxide (CO2) retention, may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
A home ventilator is 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LifeGlider Up walker. 
 
You asked the Plan to pre-approve a LifeGlider Up walker. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no indication why you cannot use the approved formulary 
UpRight walker. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a LifeGlider Up walker have not been met. Specifically, there is no indication why this walker is 
needed over the approved formulary walker. Therefore, we decided that the Plan does not have to pre-approve 
a LifeGlider Up walker.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for ultrasonic guidance for needle placement (eg, biopsy, aspiration, 
injection, localization device), imaging supervision and interpretation rendered on December 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says that charges for or in connection with services or supplies that are, as determined by us, 
considered to be experimental or investigational are excluded from coverage. 
 
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's denial would need verification from medical records. However, the 
plan did not send in any medical records for review. Therefore, we decided that the Plan has to pay for 
ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation rendered on December 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rock Steady Boxing program. 
 
You asked the Plan to pre-approve the Rock Steady Boxing program. You say that you are requesting the Rock 
Steady Boxing fitness program to treat the enrollee's Parkinsonism. The Plan denied your request. The Plan 
says Rock Steady Boxing is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only enrollees are covered for a fitness benefit through Silver Sneakers. 
 
The Plans rules for coverage of gym benefits have not been met because Rock Steady Boxing program is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve the Rock Steady Boxing 
program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve audiology services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve audiology services to be provided by an out-of-network provider. You say 
that this is the only provider in the state of Alabama that can test and treat for vestibular diagnosis, dizziness 
and imbalance. The Plan denied your request. The Plan says the records received do not indicate that the 
enrollee has an emergent or urgent medical condition or is in need of specialized service(s) that are not 
available in the network. There are in-network provider(s) within a reasonable distance from the enrollees 
location that can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve audiology 
services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iron Sucrose injections (J1756). 
 
You asked the Plan to pre-approve the Iron Sucrose injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Iron injections are covered when oral 
supplementation has been tried and the patient has demonstrated significant gastrointestinal distress whereas 
compliance with an oral regimen is no longer feasible. 
 
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 Iron Sucrose injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found the record provided 
does not indicate that oral supplementation has been tried and the patient has demonstrated significant 
gastrointestinal distress. 
 
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 Iron Sucrose injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Iron Sucrose injections (J1756).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the low back pain is the main symptom. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there were/are multiple plausible pathologic sources of significant pain generation. The 
non-radiating midline back pain, the noted pain-aggravating factors (standing, walking, range of motion, going 
from sit to stand, and going downstairs), pain-relieving factors (rest), along with the painful spinal motion (with 
an intact neurologic exam) were/are all non-specific to any pathologic entities. Overall, documentation was/is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L4, L5, and S1 levels, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept intraosseous nerve ablation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the machine requested (PCD) 
was not for peripheral artery disease, but rather for recovery from an upcoming knee replacement. The Plan 
denied your request. The Plan says you do not have peripheral artery disease. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections, anesthetic agent(s) and/or steroid; sciatic 
nerve (64445, 77002). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says the sciatic nerve injection code 
(64445) should not be used to report a piriformis injection. 
 
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 64445 is not supported in the medical record. Specifically, Medicare guidelines confirm 
that when the clinical notes reflect direct nerve block to the sciatic nerve, 64445 should be used. When the 
injection focus is in the piriformis muscle or surrounding muscle groups, 20552 should be used. The records 
confirm that the injection is for use in the piriformis muscle, therefore, code 64445 cannot be used. Based on 
this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injections, anesthetic agent(s) and/or steroid; sciatic nerve 
(64445, 77002).
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still unstable and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
   
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that Botulinum is a significant adjunct to complex 
abdominal wall reconstruction. The Plan denied your request. The Plan says the enrollee does not have an 
indication for use per Medicare Guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 Botox. Our physician reviewer found 
there is no documentation that the Botox injections at issue in this case meet all Medicare criteria for medically 
reasonable and necessary and safe and effective for the enrollee. Our reviewer also found that paralysis of 
abdominal wall muscles as part of a complex abdominal wall hernia repair procedure is not cited in the LCD or 
the Medicare-approved major drug compendia as a medically accepted indication for use of Botox injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
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 an LTACH admission is medically 
appropriate for the enrollee, and you would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says admission to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 this is a life sustaining device, and the 
enrollee has already been on bilevel positive airway pressure (BiPAP) in the hospital and still remains 
hypercapnic. You also say that this enrollee will not live comfortably without this trilogy, and it may cause 
harm or death if it is not approved. The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in average volume-assured pressure support (AVAPS) mode with Auto-Expiratory 
Positive Airway Pressure (EPAP) 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 a home ventilator is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the enrollee was recently hospitalized after being found to be profoundly hypoxemic prior to an elective 
colonoscopy. The enrollee has severe obesity and heart failure with preserved ejection fraction (HFpEF). 
Arterial blood gas (ABG) in the hospital was consistent with severe acute on chronic hypercarbic respiratory 
failure. Our reviewer found that the enrollee improved on BiPAP. COPD is mentioned as a possible diagnosis, 
but there is no prior history of COPD, smoking history is not provided, and there are no pulmonary function 
tests. Our physician reviewer found that obesity hypoventilation syndrome was the leading consideration for 
the etiology of the carbon dioxide (CO2) retention. This enrollee may benefit from BiPAP during sleep as an 
outpatient. This has not been shown to fail as an outpatient. Our physician reviewer also found that 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found Medicare does not consider this surgery to be an inpatient procedure. The enrollee can stay in the hospital after surgery without being admitted, even if the enrollee stays for more than one day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on October 17, 2021. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this claim 
is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 27, 2021. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the ambulance services have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on October 17, 2021.