Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 120 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 120 home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 120 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that you require additional skilled nursing services to provide treatment that is 
medically necessary. You do not require additional skilled nursing services to effectively provide treatment, 
care, and/or services in order to improve your condition, perform a maintenance program to maintain your 
condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 120 home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 120 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective internal radiation therapy. 
 
You asked the Plan to pre-approve selective internal radiation therapy. 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 selective internal radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the liver disease appears to be the most life-threatening (compared to 
her bone metastases) it is not evident that systemic options have become ineffective. As such, 
radioembolization, offered for routine practice, would not be furnished in accordance with accepted standards. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective internal radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve selective internal radiation therapy.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and records do not show that you require an 
intensive team that an IRF would provide, for you to reach your functional goals. 
 
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 while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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 the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is considered experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy before coverage can be approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
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 an LTACH is the medically appropriate 
level of care and the most optimal opportunity for a successful outcome. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met. The Plan says that the enrollee is receiving the care 
needed in the hospital where she is now and there is no need for transfer to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 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 health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Favorable

 
We decided that the Plan has to pay for ambulance mileage provided on October 7, 2021. 
 
You asked the Plan to pay for ambulance mileage. You say that this is not a duplicate charge, and this trip 
never had the mileage paid although the base rate was paid. The Plan denied your request. The Plan says that 
the denial of payment for this service is correct, because this service is not covered. 
 
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. The Plan denied this claim on the basis that ambulance mileage is not covered. 
However, ambulance mileage is Medicare-covered and in fact Medicare instructs ambulance providers that a 
separate mileage code is generally a required element when billing for ambulance service. The Explanation of 
Benefits submitted by the Plan indicates that the mileage was denied due to transportation being not medically 
necessary. However, this is inconsistent with the Plans coverage of the base ambulance rate as the mileage is 
an integral aspect of the base ambulance service. Finally, the Plan did not submit a copy of the original claim 
form billed for this claim. Without a copy of the original claim form, we cannot determine whether a 
billing/coding error may have occurred on this claim. In conclusion, the Plan has not shown that its decision to 
deny payment for this claim is correct or justified according to Medicare rules. Therefore, we decided that the 
Plan has to pay for ambulance mileage provided on October 7, 2021.  
 
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 needle electromyography (95886), nerve conduction 
studies (95907) and unlisted neurological or neuromuscular procedure (95999) provided on June 17, 2021. 
 
You asked the Plan to pay for the needle electromyography (95886), nerve conduction studies (95907) and 
unlisted neurological or neuromuscular procedure (95999). You say that the services were requested out of 
medical necessity by the in-network doctor at an in-network facility. You say that the denial of this claim is not 
justified, and you are requesting the claim be processed. The Plan denied your request. The Plan says procedure 
codes 95886, 95907 and 95999 are not supported by the medical records submitted. 
 
  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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 95907 is nerve 
conduction studies; 1-2 studies. The CPT Code Manual definition of code 95999 is 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 the needle electromyography (95886), nerve conduction 
studies (95907) and unlisted neurological or neuromuscular procedure (95999). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
CPT code 95907 would not be reported for the service described, and therefore would not be covered. Per CPT 
guidelines, CPT code 95866 is done with a nerve conduction study. In this case nerve conduction studies 
cannot be verified; therefore, this procedure would not be covered. The procedure report also does not include 
documentation of an unlisted procedure.  
 
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 needle electromyography (95886), nerve conduction studies (95907) and 
unlisted neurological or neuromuscular procedure (95999) have not been met. Therefore, we decided that the 
Plan does not have to pay for the needle electromyography (95886), nerve conduction studies (95907) and 
unlisted neurological or neuromuscular procedure (95999) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural injection service. 
 
You asked the Plan to pre-approve epidural injection services. You say that this injection service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) services 
when the first injection directly and significantly provided improvement of the condition being treated may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months.  
 
We looked at the file and Medicare rules. In this case, the documentation indicates that less than three months 
had passed when these repeat ESI services were requested. Based on this information, we decided that 
Medicare rules for coverage of epidural injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat epidural injection service.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of hypoglossal nerve neurostimulator. 
 
You asked the Plan to pre-approve implantation of hypoglossal nerve neurostimulator. You say that this device 
is necessary for your condition. 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 a hypoglossal nerve neurostimulator is subject to the 
coverage criteria 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 implantation of hypoglossal nerve 
neurostimulator. Our reviewer says that the requested device is not medically reasonable and necessary. Our 
physician reviewer found that the review indicates that Medicare requires documentation that demonstrates 
CPAP failure (defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 
hours per night, 5 nights per week or the CPAP has been returned) including shared decision making that the 
patient was intolerant of CPAP despite consultation with a sleep expert; and Absence of complete concentric 
collapse at the soft palate level as seen on a drug-induced sleep endoscopy (DISE) procedure; and no other 
anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per standardized 
tonsillar hypertrophy grading scale). Those criteria were not met. The review has determined that the enrollee 
does not satisfy the coverage criteria for the requested hypoglossal nerve neurostimulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of hypoglossal nerve neurostimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve implantation of hypoglossal nerve 
neurostimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trifecta ViaCell allograft and bone marrow aspirate. 
 
You asked the Plan to pre-approve Trifecta ViaCell allograft and bone marrow aspirate. 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 Trifecta ViaCell allograft and bone 
marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found Trifecta allograft and bone marrow aspirate are 
experimental when used as bone graft material in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trifecta ViaCell allograft and bone marrow aspirate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Trifecta ViaCell allograft and bone marrow 
aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alert or alarm device (A9280). 
 
You asked the Plan to pre-approve the alert or alarm device. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this is device is not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that that telephone alert systems will be denied as 
noncovered because these are emergency communications systems and do not serve a diagnostic or therapeutic 
purpose. Based on this information, we decided that Medicare rules for coverage of the alert or alarm device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the alert or alarm device 
(A9280).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care and if supervision cannot be provided in your 
home, then skilled services can be provided on an intermittent outpatient basis, in a long-term care facility, or 
at the home with home health 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (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 skilled nursing facility (SNF) care.
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 you had renal failure and now need hemodialysis. 
You say that you are very weak and need rehabilitation to regain your strength. The Plan denied your request. 
The Plan says the guidelines for coverage have 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 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 worsening renal failure and hyperkalemia. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.