Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet denervation (64635). 
 
You asked the Plan to pre-approve facet denervation. You say that the enrollee needs this procedure. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary after the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks (MBBs). 
 
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 facet denervation. Our reviewer says that the requested facet denervation is not medically necessary. Our physician reviewer found there is no 
documentation of prior diagnostic medial branch blocks (MBBs). Therefore, the reviewer found that facet 
denervation 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 facet denervation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet denervation (64635).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on March 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan does not have the information needed to consider this 
charge. 
 
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 not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate the denial based on review of the medical records submitted by the provider. Therefore, we 
decided that the Plan has to pay for laboratory services provided on March 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air ambulance from Dominican Republic to Rhode 
Island (A0430, A0435). 
 
 
 
 
 
 
 
 You asked the Plan to pre-approve an air ambulance. You say that the enrollee suffered an ischemic stroke on 
February 21, 2023, and she is not getting the proper care. The enrollee is paralyzed on the right side, no motor 
function, not being medicated with anything except a product similar to Ensure. The enrollee cannot walk or 
speak, and family had to hire separate nursing staff to care for her. The enrollee will have better care in Rhode 
Island than she is receiving in Dominican Republic. The Plan denied your request. The Plan says there is no 
medical documentation submitted indicating that the enrollee needs to be transferred from one hospital to the 
nearest appropriate hospital and that the transferring hospital does not have the appropriate facilities to provide 
the medical services that the enrollee needs such as trauma unit, burn unit or cardiac care unit. Therefore, the 
enrollee does not meet criteria for coverage and this service will not be reimbursed. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 an air ambulance. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation does not support 
that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than 
ambulance. The enrollee was admitted for an acute left ischemic atherosclerotic stroke and stage I hypertension 
on February 22, 2023. Documentation states that she is stable with a Glascow score of 15/15, dysarthria, and 
residual right hemiparesis. The documentation does not support a need for ALS or BLS support during 
transport. The documentation does not support that the enrollee's condition was such that the time needed to 
transport an enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's 
survival or seriously endangered her health. The enrollee is stable at the time transfer is requested. The 
documentation does not support that the transferring hospital did not have adequate facilities to provide the 
medical services needed by 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 an air ambulance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an air ambulance from Dominican Republic to Rhode Island (A0430, A0435).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you have a past medical history of stroke x 2, diabetes, craniotomy for Moyamoya 
syndrome and are living at home with weakness and increased spasticity of upper extremity. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual physical exam provided on October 20, 2022. 
 
You asked the Plan to pay for the annual physical exam. You say that your Evidence of Coverage with the Plan 
says that annual physical exams are covered. The Plan denied your request. The Plan says that your providers 
office may have billed for a service that Medicare does not cover or they may have used a billing code that 
Medicare does not recognize. It is their responsibility to correct those problems and resubmit the claim. 
 
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 not provided us with a Medicare rule, a Plan rule or a 
coding rule to substantiate their denial. Additionally, the Plan has not provided us with the network status of 
the referring provider or the servicing provider. The Plan has not shown that the Plan has made outreach to the 
provider to confirm if the code billed (99397) was the intended code to bill or if the provider needed to rebill 
the Plan with a more accurate code (G0438), which is an annual wellness visit. The Plan has not provided 
confirmation that the provider has no intent to bill the enrollee. Therefore, we decided that the Plan has to pay 
for the annual physical exam provided on October 20, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomographic angiography (CTA) of the abdominal aorta 
with imaging to include the arteries of the legs. (75635) 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the notes from your last physician 
visit on March 6, 2023, indicates your history as "known descending aortic aneurysm having increased in 
diameter from 3.1-3.8 cm. There is no ultrasound report enclosed. It is assumed that the history was inaccurate 
and the intention was likely to have been to request the CTA of the abdominal aorta with imaging to include 
the arteries of the legs for an increase in size of an abdominal aortic aneurysm. If this is the case, the request for 
the CTA, would be a reasonable and indicated exam as a 7mm increase in diameter of an abdominal aortic 
aneurysm would be considered a possible surgical indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomographic angiography (CTA) of the abdominal aorta with imaging to include the arteries 
of the legs. (75635)  
 
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 cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has not had non-invasive testing, such as a stress test. Guidelines do not 
support a need for invasive cardiac catheterization in this setting. As a result, at this time cardiac catheterization 
would not be considered medically appropriate and necessary in this enrollees 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the home ventilator supply items are 
medically necessary. The Plan denied your request. The Plan says that the requested device does not meet the 
requirements for approval. The records show that the standard written order from your provider is for airway 
pressure settings (AVAPS) that can be delivered with a BiPAP machine. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee has amyotrophic lateral 
sclerosis with increasing shortness of breath. Pulmonary function tests have shown gradually worsening 
restrictive lung disease and markedly reduced inspiratory and expiratory mouth pressures. An arterial blood gas 
in November 2022 showed mild CO2 retention. The enrollee has a progressive neuromuscular disease and 
currently meets criteria for nocturnal ventilatory support. As the enrollee's respiratory compromise worsens, 
daytime sip and puff ventilation will become necessary, as well as alarms and battery backup. The home 
ventilator is therefore medically necessary, and the denial is reversed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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 the additional moderate sedation time provided on date of 
service October 13, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 13, 2022, billed 
with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs a noninvasive home 
ventilator. The Plan denied your request. The Plan says the requested device does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
in acute on chronic hypercarbic respiratory failure, with a diagnosis of COPD confirmed on previous 
pulmonary function tests. The enrollee improved as an inpatient on treatment, including BiPAP. This enrollee 
may benefit from BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy with 29 fractions (77014, 77520, 
77522, 77523, 77525, G6002). 
 
You asked the Plan to pre-approve proton beam therapy with 29 fractions. You say that the requested therapy is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the request does not meet 
Medicare or health plan coverage criteria. 
 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 Proton Beam Therapy with 29 
fractions. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while he does not think that proton therapy is an 
experimental therapy, any potential benefit or detriment of proton therapy over standard IMRT is an 
investigational question (being pursued in randomized studies, i.e., for intermediate to low-risk prostate cancer.  
Other treatment approaches (IMRT +/- IGRT) are also highly effective and well tolerated. Thus, whether 
proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of 
investigation and remains controversial. Particularly, with the use of the SpaceOAR hydrogel spacer, the risk of 
GI/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more unlikely that 
there would be a potential benefit from proton therapy. To date, there are no compelling data to suggest that 
proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for 
prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. 
The decision is unfavorable as the LCD criteria is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Therapy with 29 fractions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton beam therapy with 29 fractions (77014, 77520, 
77522, 77523, 77525, G6002).
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 enrollee still needs skilled care for physical and 
occupational therapy. The Plan denied your request. The Plan says your request for approval of continued 
admission in a SNF does 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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee's function was at or near their prior level of function and they could be 
discharged to a lower level of care for further services. 
 
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 Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is medically necessary. The Plan denied 
your request. The Plan says a trial of bevacizumab is required before alternatives can be considered. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.