Persius/hicric huggingface dataset:
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 are medically stable, with no new medical issues. You do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy in an IRF. Your rehab can be safely provided at a lower intensity and alternate setting 
such as in a skilled nursing facility. 
 
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 the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the Interspinous/interlaminar process spacer device is considered 
experimental and is unproven for all indications. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response without transport provided on January 
24, 2021. 
 
You asked the Plan to pay for ambulance response without transport. You say that this bill should be paid by 
the Plan. The Plan denied your request. The Plan says ambulance response without transport is not covered by 
Medicare. 
 
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 January 24, 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 ambulance response 
without transport provided on January 24, 2021.
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 (A0428) and ground mileage (A0425) provided August 18, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this charge is not included in the payment 
bundle. The Plan denied your request. The Plan says this transportation is not separately billable. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. Medicare rules 
say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another 
hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the 
original provider. This movement of the patient is considered "patient transportation" and is covered as an 
inpatient hospital service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient to the skilled nursing facility (SNF) when the enrollee was transported for care. This 
means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-
emergency transport (A0428) and ground mileage (A0425) provided August 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS). 
 
You asked the Plan to pre-approve diagnostic test. You say that the requested service is necessary. The Plan 
denied your request. The Plan says the requested service does not meet the criteria for coverage. 
 The Plan follows Medicare rules. Medicare rules say that MRgFUS is not medically necessary for treatment of 
beneficiaries who have an advanced neurodegenerative condition. 
 
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 diagnostic test. Our reviewer says that 
the requested diagnostic test does not meet the criteria for coverage. Our physician reviewer found based on the 
provided documentation, the requested procedure (MRgFUS) is not covered in patients with a 
neurodegenerative condition. The reviewer found that the medical records did not otherwise demonstrate that 
all of the other requirements for the performance of this procedure were met/satisfied (within the first part of 
the LCD). Therefore, the reviewer found that the requested service does not meet Medicare criteria for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport (A0428, A0425) provided on July 25, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says the ambulance transport does not meet the Medicare coverage criteria. 
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found that the record indicates that the enrollee was transported from the emergency 
department back to skilled nursing facility. The record indicates that the enrollee was transported via stretcher.  
The record does not indicate that the enrollees clinical condition is such that other methods of transport are 
contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on July 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport (A0428, A0425) provided on October 14, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says the ambulance transport does not meet the Medicare coverage criteria. 
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance service, basic life support, non-emergency 
transport was not medically necessary. Our physician reviewer found that the enrollee has a history of 
rheumatoid arthritis who was able to walk to the cot upon ambulance arrival. The enrollee was going to and 
from cataract surgery. The review has determined that the documentation did not support that other means of 
transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated 
for this enrollee on October 14, 2021. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport on October 14, 2021. The documentation did not support that the ambulance transport on 
October 14, 2021 was medically reasonable and necessary 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 ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital observation care, per hour (G0378-GZ) provided 
on August 23, 2021. 
 
You asked the Plan to pay for hospital observation care. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says this service was not billed correctly, as code G0378 is not allowed to be 
reported more than once per claim. This code was reported twice on this claim on different lines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that items and services 
that are not medically necessary are not covered. Medicare rules state that items submitted with a GZ modifier 
shall be denied automatically and will not be subject to complex medical review. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, this service was reported 
twice on two claim lines, and the second line includes the GZ modifier, which by definition means that these 
services do not meet the criteria for Medicare coverage.  Based on this information, we decided that Medicare 
rules for coverage of hospital observation care have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital observation care, per hour (G0378-GZ) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pentamidine isethionate, inhalation solution (J2545) 
provided on June 21, 2021. 
 
You asked the Plan to pay for the pentamidine isethionate, inhalation solution (J2545). You say that the 
documentation supports this code is a valid code and there are no applicable replacements. You say that the 
claim should be reprocessed accordingly for payment. The Plan denied your request. The Plan says the code is 
not recognized by the Outpatient Prospective Payment System (OPPS). 
 
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 J2545 is pentamidine isethionate, inhalation solution, fda-
approved final product, non-compounded, administered through dme, unit dose form, per 300 mg. 
  We find that CPT code J2545 is not supported in the medical record. Specifically, CPT code J2545 has a status 
indicator of B. This means that CPT code J2545 is not a recognized code under the Outpatient Prospective 
Payment System and cannot be paid when billed on an outpatient claim. Based on this information, we decided 
that Medicare rules for coverage of the pentamidine isethionate, inhalation solution (J2545) have not been met. 
Therefore, we decided that the Plan does not have to pay for the pentamidine isethionate, inhalation solution 
(J2545) provided on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gender reassignment surgery (15877, 19305, 19303). 
 
You asked the Plan to pre-approve the gender reassignment surgery. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the gender reassignment surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has gender dysphoria. The record indicates 
that the enrollee has been receiving hormone therapy. However, the record provided is insufficient to establish 
the medical necessity of the requested surgical 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 the gender reassignment surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve gender reassignment surgery (15877, 19305, 19303).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, custodial and intermittent, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four abutment supported crowns (D6063) and four 
implant supported crowns (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
abutment supported crowns (D6063) and four implant supported crowns (D6065).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and 
ground mileage (A0425) provided on June 1, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee had 2 round trips on the date of 
service in this case. You say that the first trip was denied. You say that the second trip was paid. You also say 
that the first trip should be paid. The Plan denied your request. The Plan says the ambulance services were 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 services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for 
the enrollee. The reviewer found that the documentation does not support that the enrollee needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. The reviewer also found that ehe documentation does not support that the ambulance transport on June 1, 2021 was medically reasonable and necessary 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) 
provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept 
procedure in the setting of vertebrogenic low back pain, lumbar spondylosis, and lumbar degenerative disc 
disease has not been demonstrated in the peer-reviewed 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 requested services are not considered medically reasonable and necessary in this case. The 
intracept procedure is experimental. More research is needed to show safety and efficacy. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network retinal specialist. 
 
You asked the Plan to pre-approve these services. You say that you would like to continue with this doctor. The 
Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The file shows that you have an 
appointment scheduled with a network provider on April 15, 2022. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network retinal specialist.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be somewhat unstable still and should only require short-term 
additional acute care services for weaning and more permanent and stable feeding source that can be safely 
completed at the current facility until more appropriate for transfer. There are no services at the LTACH that 
you require that are not already available and covered at the current facility. Transfer may be considered when 
treatment has completed and you are more stable. 
 
 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.