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

 
We decided that the Plan does not have to pay for the emergency ambulance transport (A0427), and ground 
mileage (A0425) provided on January 24, 2021. 
 
You asked the Plan to pay for the transportation services. You say that you have billed hospice. You say that it 
was denied stating the enrollee was not under their care for the date of service. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency ambulance transport (A0427), and ground 
mileage (A0425) provided on January 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 April 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity doppler study to be rendered by the 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a lower 
extremity doppler study to be rendered by the out-of-network (OON) provider.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have skilled nursing or therapy needs. 
 
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 the submitted records show that the enrollee 
has no identifiable skilled nursing needs. While the enrollee has skilled therapy needs, he does not need therapy 
services on a daily 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 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 24 treatments of Iron sucrose for the enrollee. 
 
You asked the Plan to pre-approve 24 treatments of Iron sucrose. You say that this is medically necessary. The 
Plan denied your request. The Plan says that a maximum of six (6) doses may be requested per authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 24 treatments of Iron sucrose. Our 
reviewer says that 24 treatments of Iron sucrose is not medically reasonable and necessary. Iron sucrose is not 
FDA-approved for the enrollees diagnosis. Excessive amount could lead to iron overload. The use of 24 
treatments of Iron sucrose is not supported by one of the major drug compendia or by clinical research that 
appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of 24 treatments of Iron sucrose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 treatments of Iron sucrose have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 24 treatments of Iron sucrose for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided October 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like the hearing aids covered. The Plan 
denied your request. The Plan says the hearing aids aren't covered because they were provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans hearing network providers.  
 
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing 
aid, digital, binaural, behind the ear (V5261) provided October 28, 2021, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minimally Invasive Lumbar Decompression (MILD) in 
combination with implantation of the Vertiflex device. 
 
You asked the Plan to pre-approve lumbar surgery services. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 73-year-old female who is being treated for spinal stenosis, 
lumbar region with neurogenic claudication. She presented with lumbar spine pain with radiation to the 
bilateral hips. Pain is worse with standing and walking and improved with forward flexion and sitting down. 
MRI is noted to show moderate stenosis at the L4-5 level. 
 
 However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. Food and Drug Administration (FDA) indications include implantation of the Superion device at one 
or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is 
indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, 
many not at FDA indicated levels of moderate spinal stenosis (including the planned level of implantation 
L4-5 level.) FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which 
have not been adequately addressed in the medical records. 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 request for Minimally Invasive Lumbar Decompression (MILD) in combination with 
implantation of the Vertiflex Superion interspinous device at L4-5 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 lumbar surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Minimally Invasive Lumbar Decompression (MILD) in combination with 
implantation of the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's diabetes is under poor 
control. The Plan denied your request. The Plan says the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder treatments rendered on January 2, 2020 to July 
25, 2020. 
 
You asked the Plan to pay for these services. You say that you were not aware of a claim filing limit. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The rules say that the only chiropractic 
service Medicare covers is manual manipulation of the spine to correct a subluxation. 
 
The record shows that a claim for these services was not filed until November 9, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Furthermore, the services 
at issue are billed with code 23650 (closed treatment of shoulder dislocation). These services are not covered 
when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the shoulder 
treatments rendered on January 2, 2020 to July 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on May 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that you do not remember having the service done. 
The Plan denied your request. The Plan says how the testing would impact care was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications.  
 We looked at the file and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to 
make decisions about your medications. Medications should be provided based on the presence of a diagnosis 
and should be adjusted based on a response to the medication. It is not necessary to do genetic testing to 
provide or adjust medications. Furthermore, genetic markers may or may not correlate with actual clinical 
findings. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing 
provided on May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) non-emergent routine transportation trips per 
week (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee is handicap 
and cannot drive. You also say the enrollee has physical therapy (PT) visits 3 times per week and other 
appointments scheduled on the days he does not have PT. The enrollee needs 10 one-way rides per week. He 
does not have any other means of transportation to get to his appointments. The Plan denied your request. The 
Plan says additional trips would exceed your benefit limit. 
 
 
 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 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
nineteen (19) one-way transportation trips out of the allowed twenty (20) one-way trips approved. Once 20 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve ten (10) non-emergent routine transportation trips per week (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is not enough 
evidence showing the requested device would improve the outcome of enrollee's condition. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system CardioMEMS for management of congestive heart failure in this 
patient. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure. The clinical study on which FDA approval was 
based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. 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 patients 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS) 
unit. 
 
You asked the Plan to pre-approve a TENS unit. You say that you were not aware that post surgery there would 
be a specific timetable for coverage of the TENS unit. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is limited to 30 days coverage from 
the day of the surgery for acute post-operative pain.  
 
We looked at the file and Medicare rules. In this case, more than 30 days have passed since your surgery. 
Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator 
(TENS) unit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy in your home, occupational therapy in 
your home, speech therapy in your home, and home health aide services. 
 
You asked the Plan to pre-approve home health services. You say that you need these services that are 
currently being performed by your power of attorney (POA). You say that this is hindering their ability to work. You also say that you have been home from the rehabilitation facility for weeks with no care at home. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
documentation indicates that you have been receiving outpatient physical and occupational therapy. The 
reviewer found that you have tolerated the therapy and had minimal improvement from February 18, 2022, to 
March 1, 2022. The reviewer found there is no recent documentation to indicate if you continue to require 
therapy or that you have been discharged from outpatient therapy services. The reviewer found that you have 
been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Given 
that you have been receiving outpatient therapies without documentation that you have been discharged, the 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy in your home, occupational therapy in your home, speech 
therapy in your home, and home health aide services.