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

 
We decided that the Plan does not have to pay for air ambulance services (A0431, A0436) provided on 
November 18, 2021. 
 
You asked the Plan to pay for air ambulance services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says information provided at the time of the appeal does not support criteria 
for air ambulance transport. 
 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 air ambulance services. Our reviewer says 
that the service was not medically necessary. Our physician reviewer found 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 the enrollee's 
health.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance services (A0431, A0436) provided on November 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional non-emergency transportation. 
 
You asked the Plan to provide additional non-emergency transportation. You say that you are requesting a 
reconsideration of additional transportation trips. The Plan denied your request. The Plan says The 2022 EOC 
clearly states 100 one-way trips per calendar year are covered, while the 101st and beyond is not a covered 
benefit. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
Based on this information, we decided that Medicare rules for coverage of additional non-emergency 
transportation have not been met. Therefore, we decided that the Plan does not have to provide additional non-
emergency transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service May 9, 2022. 
 You asked the Plan to pay for procedure code 77065. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 77065 billed for date of 
service May 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
with intolerance to oral iron replacement. He has not tried and failed the Plan's required drugs, Infed and 
Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Feraheme 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of shoulder (73221). 
 
You asked the Plan to pre-approve an MRI of shoulder. You say that the service is medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of shoulder. Our reviewer says 
that the enrollee meets criteria for coverage. Our physician reviewer found the enrollee has positive empty can 
test and the x-ray report of September 4, 2022, showed degenerative changes in glenohumeral joint. The prior 
history of rotator cuff repair and the plain x-ray findings of degenerative changes qualify her for approval of 
the requested MRI of the right shoulder. 
 
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 MRI of shoulder have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) of shoulder (73221).  
 
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 an epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve an ESI. You say that the enrollee does not want to have surgery. You also 
say that the enrollee's primary care physician (PCP) is aware of the steroid use. The Plan denied your request. 
The Plan says the request injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that frequent continuation of epidural steroid injections 
over 12 months requires rationale for the continuation of ESIs including but not limited to patient is high-risk 
surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with 
ESIs for at least three months.  
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 ESI. Our reviewer says that the 
requested ESI does not meet the criteria for coverage. Our physician reviewer found that the provided 
documentation does not indicate that the enrollee is high-risk to undergo surgery or does not want surgery. 
Therefore, the reviewer found that the criteria for coverage have not been 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure.  
You asked the Plan to pre-approve percutaneous left atrial appendage closure. You say that percutaneous left 
atrial appendage closure is medically necessary. The Plan denied your request. The Plan says percutaneous left 
atrial appendage closure does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the patient must have a suitability for short-term 
warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision 
making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
 
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 percutaneous left atrial appendage 
closure. Our reviewer says that percutaneous left atrial appendage closure is not medically necessary. Our 
physician reviewer found at issue is the medical necessity of implanting a LAAC device in this enrollee in 
whom there is an elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC 
score. There is no contraindication to anticoagulation according to the physician. As such, guidelines would not 
support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered 
reasonable or medically 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 percutaneous left atrial appendage closure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that you would like to see this provider due to 
their expertise. The Plan denied your request. The Plan says in-network providers are available for necessary 
care. 
 
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. 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external counterpulsation (ECP) therapy. 
 
You asked the Plan to pre-approve ECP therapy. You say that this is the only non-invasive, disease modifying 
treatment for coronary artery disease. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or under this contract. 
 
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 ECP therapy. Our reviewer says that 
ECP therapy services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found stress testing revealed no chest pain at an exercise level above 11 metabolic equivalents 
(METs.) It is unclear whether the enrollees chest pain is due to cardiac ischemia. Also, the documentation 
does not indicate that optimal anti-anginal therapy has been implemented. As such, it is premature to consider 
ECP. In summary, there is insufficient documentation to support the medical necessity for the use of ECP 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 ECP therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve external counterpulsation (ECP) therapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing applied to the skilled nursing facility claim 
for dates of service April 1, 2022, through April 14, 2022. 
 
You asked the Plan to waive the cost sharing applied to the skilled nursing facility claim for dates of service 
April 1, 2022, through April 14, 2022. You say that the enrollee should not have to pay these charges. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $188 copayment per day for days 21-100 for skilled nursing facility care.  
 
   
The enrollee has been asked to pay a $564 ($188 x 3 = $564) copayment for the skilled nursing facility claim 
for dates of service April 1, 2022, through April 14, 2022. This item/service falls within the skilled nursing 
facility care benefit category. The enrollee was admitted to the skilled nursing facility on March 21, 2022. The 
20
th
 day of the skilled nursing facility stay was April 10, 2022. Cost sharing was correctly applied to dates 
April 11, April 12, and April 13, 2022. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing applied 
to the skilled nursing facility claim for dates of service April 1, 2022, through April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36226 and 36228) provided 
on March 2, 2022. 
 
You asked the Plan to pay for the selective catheter placement (36226 and 36228). The Plan denied your 
request. The Plan says procedure codes 36226 and 36228 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 36226 is selective catheter placement, vertebral artery, 
unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision 
and interpretation, includes angiography of the cervicocerebral arch, when performed. The CPT Code Manual 
definition of code 36228 is selective catheter placement, each intracranial branch of the internal carotid or 
vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological 
supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in 
addition to code for primary 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 selective catheter placement (36226 and 36228). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that a selective catheter placement, vertebral artery, with angiography of ipsilateral vertebral 
circulation was not found in operative report. In addition, a selective catheter placement for each intracranial 
branch of the inter carotid or vertebral arteries cannot be confirmed. Therefore, these procedures cannot be 
verified. 
 
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 selective catheter placement (36226 and 36228) have not been met. 
Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36226 and 
36228) provided on March 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976.  
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, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance services (A0429, A0425) provided on 
May 17, 2022. 
 
You asked the Plan to pay for emergency ambulance services. You say that you want the Plan to pay for the 
services. The Plan denied your request. The Plan says the services were not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. 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 emergency ambulance services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found your presenting 
symptoms did meet prudent layperson criteria for emergency care. The presenting complaint was bleeding from 
a "dime sized" area of the foot which was controlled with direct pressure and a bandage. While medical follow 
up was necessary, the situation did not require emergency 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 emergency ambulance services have not been met. Therefore, we decided that 
the Plan does not have to pay for emergency ambulance services (A0429, A0425) provided on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that they want to discharge you from the hospital but are 
only able to walk 10 feet with assistance. You say that they want you to get therapy to gain strength back 
before going back home. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can safely receive the services you need at an alternate level of care. 
 
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 you have no complex nursing and rehabilitation needs. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration based on 
records submitted. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the enrollee can safely receive the services they need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on February 1, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
that the member was enrolled in hospice on this date of service and traditional Medicare is responsible for 
payment. 
 
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 proof of hospice enrollment on 
this date of service. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided 
on February 1, 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.