Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide. 
 
You asked the Plan to pay for a stair glide. You say that you need this item. The Plan denied your request. The 
Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal Infection PCR panel coded as 87798 and 87481 
provided August 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are attaching the medical records which 
shows medical necessity. Please review for payment. The Plan denied your request. The Plan says this service 
is considered experimental and investigational and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Fungal Infection PCR panel coded as 87798 and 87481 provided August 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on May 12, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport service was not medically necessary. 
Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's nursing home 
was not medically necessary. The enrollee was not bedbound, as evidenced by the ability to sit in a chair and 
ambulate. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 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 the ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (C2624 and 33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says there is not enough medical evidence that shows use of the device is helpful, safe 
and improves the quality of life. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (C2624 and 33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
(87798, 87541) provided on September 9, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that panels with >5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel (87798, 87541) provided on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on August 9, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel provided on August 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, buprenorphine (oral) (code G2068) 
provided on October 10, 2022. 
 
You asked the Plan to pay for medication assisted treatment, buprenorphine (oral). You say that you have been 
enrolled in the Medicare program to provide Opioid Treatment Program (OTP) services since  
January 01, 2020. The Plan denied your request. The Plan says that an individual provider cannot bill for OTP 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, buprenorphine (oral) (code G2068) provided on October 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the posterior lateral fusion at L5-S1 with Inspan device 
(22840 and 22612). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says interspinous-interlaminar fusion surgery and the devices used for it remain 
experimental for use. The Plan states more research is needed to show safety and efficacy of the procedure and 
the devices. The Plan states the clinical value and effectiveness of the Inspan interspinous device in the setting 
of lumbar stenosis have not been demonstrated in the peer-reviewed literature. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested posterior lateral fusion 
at L5-S1 with Inspan device, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the posterior lateral fusion at L5-S1 with Inspan device (22840 and 22612).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from October 26, 2021, to  
March 2, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the claim does not 
meet criteria for approval due to the service was rendered by an out-of-network provider without 
pre-authorization, there is no PCP referral, there is no evidence of an emergency and there are contracted 
providers in members residence area. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided from October 26, 2021, to  
March 2, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
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 the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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, 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628 and 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on June 20, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not been evaluated by respiratory therapy for a portable oxygen 
concentrator. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that you are 
on home supplemental oxygen and are requesting a portable oxygen concentrator because of difficulty 
managing the oxygen tubing. There is no evidence that you have tried portable oxygen tanks, or that they 
would not meet your needs. There is no documentation that oxygen levels can be maintained above 91% while 
on oxygen at 1 to 4 liters/min using an oxygen conserving device. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that use of an intrapulmonary percussive ventilator (IPV) in the home is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say IPV in the home setting 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 the device. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found that the Volara 
system is not a traditional high frequency chest wall oscillation device; the Volara system oscillates "the 
airways with continuous pulses of positive pressure." This intrapulmonary percussive ventilation is not 
approved by Medicare for home use. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Volara system
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
You asked the Plan to pre-approve the stimulation. You say that this is medically necessary. The Plan denied 
your request. The Plan says there has not been full assessment for surgical problems causing the incontinence. 
 
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 stimulation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not show that the enrollee is refractive to conventional therapy. There has 
not been demonstration of adequate ability to record voiding diary data. Interstim is an acceptable third line 
treatment of overactive bladder. In this case, the enrollee has not tried/failed second line medical therapy and a 
voiding diary was not provided. As such, Interstim is not medically necessary in this case. 
 
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 stimulation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral nerve stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 32-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that the enrollee requires 
transportation to dialysis. The Plan denied your request. The Plan says the enrollee's routine transportation 
benefit is exhausted. 
 
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. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
32-trip limit.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an electroencephalogram (EEG) (procedure code 95720) rendered on 
January 3, 2022, and January 4, 2022. 
 
You asked the Plan to pay for the EEG. You say that the attached medical records support the medical 
necessity of this service. The Plan denied your request. The Plan says that this is experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the EEG. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the patient presented to the hospital and was unresponsive. The enrollee had a prior 
neurological history. He was started on an EEG which revealed nonconvulsive status epilepticus (NCSE). The 
performance of extended long-term EEG in this scenario would be readily consistent with standards of 
care/practice. Continued monitoring of the patient was indicated given that it would impact treatment decisions 
and medication management. In as much the services under review would have met the Medicare definition of 
medical necessity. 
 
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 EEG have been met. Therefore, we decided that the Plan has to pay for an 
electroencephalogram (EEG) (procedure code 95720) rendered on January 3, 2022, and January 4, 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.