Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that medical records were submitted for review. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require an acute rehabilitation hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple  
 therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. The enrollee can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 September 9, 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 enrollee who was transported non-emergently via ambulance to a nursing 
home was not medically necessary. The enrollee was noted to be weak, unable to bear weight and was placed 
on a stretcher. The record indicates that the enrollee was not treated during transport and was medically stable. 
The enrollee did not require the expertise, services and lifesaving and life-sustaining equipment that only a 
fully equipped ambulance can provide for a safe transport.  
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 September 9, 2022.
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 member is appropriate for a long-
term acute care hospital. The Plan denied your request. The Plan says an LTACH admission is not currently 
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 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 health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
 
  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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's mileage limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need reliable 
transportation. The Plan denied your request. The Plan says the requested transport exceeds your mileage 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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 We looked at your request, the records in the case file, and the rules. We confirmed that the requested trip is 
greater than 50 miles of driving distance. 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 additional miles for routine transportation beyond the Plan's mileage limit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is at high risk for falling and requires 
physical therapy to increase their strength. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a bariatric orthopedic mattress (E0272). 
 
You asked the Plan to pre-approve a bariatric orthopedic mattress. You say that the requested item is necessary. 
The Plan denied your request. The Plan says that the item is not a covered service. 
 
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. Clarifying questions were sent to the Plan and no response was received. 
Additionally, medical records were requested and never received. Without this information, the plan's denial is 
not able to be substantiated. Therefore, we decided that the Plan has to pre-approve a bariatric orthopedic 
mattress (E0272).  
 
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 pay for procedure codes 99100 and 99140 billed for date of service 
October 24, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. The Plan denied your request. The Plan says 
procedure codes 99100 and 99140 are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
October 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 9, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95822-26-XU and 95999 (x3) is electroencephalogram 
recording in coma or sleep only, and unlisted neurological or neuromuscular diagnostic procedure. 
 
We asked our coder 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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the patient was not in a coma or 
sleeping during the procedure. Therefore, the provided documentation does not support the billed codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. 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 the services provided on April 18, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; single level (64490), injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; second level (64491) and injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; third and any additional level(s) (64492). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary due to your 
condition. The Plan denied your request. The Plan says the medical documentation indicates you had 70% pain 
relief from the initial procedure. Therefore, your request is denied because the medical necessity criteria 
indicated in LCD L35936 has not been met of 80%. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have chronic thoracic back pain. The available medical documentation indicates you had 
70% relief of pain from the initial procedure. According to the coverage criteria, there must be a consistent 
positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with 
the agent used) to proceed with a second procedure. The review has determined that the requested injections 
are not medically necessary for you. The review has determined that you do not meet LCD criteria for this 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level (64490), 
injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (64491) and injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (64492).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T and C1825). 
 
You asked the Plan to pre-approve the device. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Barostim Neo device is considered unproven and is not medically 
necessary 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable 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 Barostim Neo device (0266T and C1825).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Supartz knee injections for osteoarthritis (J7321 and 
J7320). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee's physician has not indicated that the formulary 
alternatives, intra-articular steroids and  Gel-One, Synvisc, or Synvisc- One, are clinically inappropriate for the 
enrollee's condition. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the Plan requires a trial of or contraindication to intra-articular steroids and Gel-One, Synvisc, or 
Synvisc-One before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Supartz knee injections for osteoarthritis (J7321 and J7320).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs further physical therapy to get 
stronger and be able to come home. The Plan denied your request. The Plan says the enrollee's condition does 
not meet the criteria for SNF services. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, records 
do not document a significant decline in the enrollees functional status to necessitate daily inpatient skilled 
therapy services. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis 
in a skilled nursing facility (SNF) setting. Records support that services in the long-term care facility on a part 
time basis are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you disagree with the denial. You are 
having surgery next month and will need the requested equipment to be mobile. The Plan denied your request. 
The Plan says Medicare says that crutch substitutes such as knee walkers have not been proven to be safe and 
effective. There is insufficient published clinical literature demonstrating safety and effectiveness in the 
Medicare population to establish the medical necessity for these products. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
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 the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. There remains a dearth of randomized, blinded clinical studies 
examining the long-term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).