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

 
We decided that the Plan has to pay for ambulance services (A0428, A0425) provided on July 15, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transport was provided after the enrollee 
was discharged from one facility and admitted to another facility. These services should be separately payable. 
The Plan denied your request. The Plan says that these services were coded incorrectly as they are included in 
the facility payment. 
 
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 provided no evidence to support that the enrollee 
maintained inpatient status at one facility or was transported to another location within the same hospital group. 
There is insufficient documentation to show that the services at issue would be considered inpatient 
transportation. The Plan's denial is not substantiated in this case, and based on the information provided, these 
services would be separately payable. Therefore, we decided that the Plan has to pay for ambulance services 
(A0428, A0425) provided on July 15, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Zenith Amniotic membrane skin (Q4253) and soft tissue 
substitute treatment (15275). 
 
You asked the Plan to pre-approve Zenith Amniotic membrane skin and soft tissue substitute treatment. You 
say that the services are medically necessary. The Plan denied your request. The Plan says these services are 
considered experimental. 
 
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 Zenith Amniotic membrane skin and 
soft tissue substitute treatment. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found these services are considered 
experimental.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zenith Amniotic membrane skin and soft tissue substitute treatment have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Zenith Amniotic membrane skin 
(Q4253) and soft tissue substitute treatment (15275).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the 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 services are not medically reasonable and necessary. Our physician reviewer found based on the 
limited documentation provided, the enrollee does not have documented skilled nursing needs or skilled 
therapy needs. 
 
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 home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted 
quality of life. The Plan denied your request. The Plan says the efficacy has been established. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. She had a minimally invasive lumbar decompression at L4/5, with some relief with the procedure. 
She is no longer in constant pain and her pain is more intermittent in nature. The exam reveals no lumbar 
findings. 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 imaging evidence of grade I anterolisthesis of L4 on L5, with no discussion of spinal instability on 
flexion/extension films. There is no documentation of the enrollees height, weight or body mass index. There 
is no discussion indicating that a bone scan has demonstrated the lack of significant osteoporosis in this 
enrollee. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex interspinous spacer 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of skin substitute (Q4173). 
 
You asked the Plan to pre-approve placement of skin substitute. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 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 placement of skin substitute. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has a chronic wound on the right hip. Per the reviewed 
documentation, the wound is improving with current treatment as evidenced by measurements and description. 
The enrollee is still undergoing debridement and is being treated with topical and oral antibiotics for treatment 
of the positive wound culture for Staph aureus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of skin substitute (Q4173).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the member meets the criteria for a SNF admission. 
The Plan denied your request. The Plan says the SNF services requested do not meet the requirements for 
approval. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing or therapy needs. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs are custodial and can, as a practical matter, be provided at a lower level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested PWC and 
accessories are medically necessary. The Plan denied your request. The Plan says that the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the medical documentation does not indicate that the enrollee is unable to accomplish mobility-related self-care tasks in the 
home without an alternative assistive device. Additionally, the enrollee does not have an appropriate diagnosis 
for a Group 3 power wheelchair. As the power wheelchair base is not medically necessary, the requested 
accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0849) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 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 lumbar magnetic resonance imaging (MRI) shoes facet degenerative joint disease 
(DJD) and disc bulges. The cause of the back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. 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 follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 VASS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the VASS in randomized controlled trials 
has not been shown to significantly improve function compared with usual prostheses. It is not medically 
necessary as the VASS is not an improvement over standard prosthesis. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum socket system (VASS) (L5781).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics (E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. The Plan denied your request. The Plan says that 
that the upgraded electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics for a power wheelchair are 
covered when it is medically necessary for the enrollee to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has been met. Our physician reviewer found that you are non-ambulatory and 
require a power wheelchair for mobility and performing your basic daily activities. You cannot perform 
pressure relief independently due to weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. You also require power elevating leg rests for positioning and your 
lower extremities. The complexity of your seating and positioning needs necessitates a more complex Group 3 
power wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the Group 3 power wheelchair base and the three power options, including, tilt, recline and elevating 
leg rests, via a joystick. Therefore, the expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311) is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics (E2311, E2377, E2313).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the 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 services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the health plans denial should be upheld.  The enrollee does not have documented 
skilled nursing needs. 
 
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 home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system identified with code E2300, 
LED lights and indicator, push handles, knee pads, high resolution joystick, backcane mount, microlite switch, 
link it mount 2, link it side mount, ankle huggers, and pads for footrests all identified with code K0108. 
 
You asked the Plan to pre-approve a seat elevation system, LED lights and indicator, push handles, knee pads, 
high resolution joystick, backcane mount, microlite switch, link it mount 2, link it side mount, ankle huggers, 
and pads for footrests. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. The requested seat elevation system is specifically not covered. The 
requested LED lights and indicator, push handles, knee pads, does not serve a medical purpose. 
The requested joystick high resolution is miscoded and there is no separate billing for control buttons, displays, 
switches, fixed mounting hardware, etc. The switch backcane mount is unbundled from the requested 
joystick/electronics and cannot be requested separately. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The requested microlite switch is already 
included with the requested expandable controller and cannot be requested separately. The requested ankle 
straps do not meet the enrollees medical needs. The requested foot pads are not properly coded as requested. 
 
Based on this information, we decided that Medicare rules for coverage of a seat elevation system, LED lights 
and indicator, push handles, knee pads, high resolution joystick, backcane mount, microlite switch, link it 
mount 2, link it side mount, ankle huggers, and pads for footrests have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a seat elevation system identified with code E2300, LED lights and 
indicator, push handles, knee pads, high resolution joystick, backcane mount, microlite switch, link it mount 2, 
link it side mount, ankle huggers, and pads for footrests all identified with code K0108.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (95810, 95811). 
 
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 polysomnography. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not show that you have a condition that would support the 
need for this testing (Significant cardiopulmonary disease, Neuromuscular disease, History of stroke, Chronic 
opiate medication use, Severe insomnia, Impaired dexterity or mobility, Cognitive impairment, Patient unable to operate home equipment or home equipment unavailable). Therefore, polysomnography is considered 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 polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography (95810, 95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #5 and 12 (D6010) and 
bone grafts at the time of implant placement on tooth #5 and 12 (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of the dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the appealed authorization. Therefore, 
we decided that the Plan does not have to pre-approve endosteal implants on tooth #5 and 12 (D6010) and bone 
grafts at the time of implant placement on tooth #5 and 12 (D6104).