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

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0435), and air mileage (A0430) provided on September 6, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the services should be covered. The 
Plan denied your request. The Plan says the air ambulance services were not medically necessary.  
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 pay for the air ambulance services. Our reviewer 
says that the air ambulance services are not medically necessary. Our physician reviewer found the 
documentation does support that the enrollee suffers from an illness or injury that contraindicates transportation 
by any means other than ambulance. The reviewer found the documentation does not support that the enrollee's 
condition was such that the time needed to transport a patient by ground, or the instability of transportation by 
ground, posed a threat to the patient's survival or seriously endangered the patient's health. She could have been 
safely transported via ground transportation. A delay in surgical consultation and treatment would have been 
acceptable as the enrollee in this case was stable. The reviewer also found the documentation does support that 
the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. 
Therefore, the reviewer found that the air ambulance services are 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0435), and 
air mileage (A0430) provided on September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for non-surgical management of facial, arm and foot fractures after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on July 14, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you called emergency medical services 
(EMS) in July. You say that they came and checked your vitals. You also say that they did not transport you. 
The Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 14, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on July 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence to support a step therapy exception. 
 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Infed and Venofer before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on September 27, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing is medically necessary for this patient. 
The Plan denied your request. The Plan says the POS code reported on this claim is not appropriate. 
 
 
 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 drug testing 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 definitive drug testing provided on September 27, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; whole body (CPT code 78816). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that the requested study would exceed the allowed limit of three (3) scans. 
 
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 PET scan. Our physician reviewer 
found the National Comprehensive Cancer Network (NCCN) Guidelines Version 5. 2022: Multiple Myeloma 
recommends the use of PET scan as needed for suspected recurrences. PET scan is superior to most imaging 
for lytic bone lesions for multiple myeloma. This enrollee has rising light chains suspicious for recurrence. The 
service is reasonable and 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
whole body (CPT code 78816).   
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: 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 enrollee can tolerate IRF level of care. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implant of a wireless pulmonary artery 
pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no records showing hospitalization for heart failure during the previous 
year. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 (CHF).  
 
 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. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcatheter implant of a wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prothrombin time (85610) and thromboplastin time 
(85730) testing services provided on September 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that these services were necessary. The Plan denied 
your request. The Plan says these tests were requested for screening purposes. Medicare does not cover these 
types of screening tests. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the prothrombin 
time (85610) and thromboplastin time (85730) testing services provided on September 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) and ground 
mileage (A0425) provided on January 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheelchair van transportation and ground mileage. You say that you would 
like this claim to be reconsidered as an exception based on medical necessity. The Plan denied your request. 
The Plan says there is no out-of-network coverage for ambulance services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) and ground mileage (A0425) 
provided on January 13, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 CGM reader. 
 
You asked the Plan to pre-approve the device. You say that the enrollee needs this device. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 is not receiving insulin 
shots three (3) times a day or using an insulin pump. 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 
Freestyle Libre 2 CGM reader.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gabapentin tablets. 
 
You asked the Plan to pre-approve gabapentin. You say that the enrollee has tried other drugs. The Plan denied 
your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered 
by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve gabapentin tablets.  
 
Benefits for gabapentin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the records provided support the need 
for the procedure being requested. You say that the Intracept procedure is not investigational and experimental 
as there is sufficient science published in peer-reviewed publications. The Plan denied your request. The Plan 
says the requested procedure is not generally accepted for the suggested use as reported in nationally 
recognized peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain.  In this case, there are multiple plausible pathologic sources of significant pain 
generation. Documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
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 pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered an experimental/investigational procedure and is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable or necessary. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing services. 
 
You asked the Plan to pre-approve BRCA genetic testing services. You say that this testing service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that the indications are listed 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 BRCA genetic testing services. Our 
reviewer says that the requested BRCA testing is not medically reasonable and necessary. Our physician 
reviewer found you are a 74-year-old first diagnosed with breast cancer at age 47 in 1994. You would not meet 
criteria for cancer given on family history and diagnosed over the age of 45. Should you be able to show that 
you were Estrogen Receptor and Progesterone Receptor negative then testing would be reasonable and meet 
coverage criteria. However, at this time the service is not reasonable or 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 BRCA genetic testing services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve BRCA genetic testing services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 28, 2020, to November 12, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the clinical documentation does not 
support that the enrollee had an active infectious disease that required isolation or quarantine during the time 
frame in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 28, 2020, to 
November 12, 2020.