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

 
We decided that the Plan has to pay for the ambulance transportation services (A0427) provided on February 
22, 2022. 
 
You asked the Plan to pay for ambulance transport billed with procedure code A0427. You say that this service 
was medically necessary and should be paid as billed at the Medicare allowed rate. The Plan denied your 
request. The Plan says that the diagnosis code billed on this claim does not support the level of care provided. 
The Plan states that this service is better described as A0429. 
 
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, although the record indicates that medical records were submitted 
to the Plan, these medical records were not forwarded to us for review. Without this documentation, we cannot 
verify the level of care furnished in this case. The Plan also does not provide any citation or supporting 
evidence to confirm that the diagnosis code billed on this claim would never be appropriate for the level of 
service at issue. Therefore, we decided that the Plan has to pay for the ambulance transportation services 
(A0427) provided on February 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve healthy groceries. 
 
You asked the Plan to pre-approve healthy groceries. You say that you would like the Plan to cover the benefit 
as listed in their contract. The Plan denied your request. The Plan says the Plan's criteria for coverage for 
healthy groceries have not been satisfied. 
 
The rules say that Medicare does not cover healthy groceries. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers healthy 
groceries when the enrollee has a chronic illness. 
 
We looked at the file and Medicare rules. In this case, we needed more information from your provider to 
demonstrate that you have been diagnosed with a chronic illness. The Plan confirmed they sent several requests 
to your provider for medical records. The Plans request for information was not returned. Therefore, we 
decided that the Plan does not have to pre-approve healthy groceries.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
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 services are not medically necessary. 
 
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 services are not medically necessary. Our physician reviewer found the Barostim Neo system is approved 
by the Food and Drug Administration (FDA) for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35 percent, and are not candidates for bi-ventricular pacing. There remains an absence of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim 
Neo in patient management. The services are therefore not reasonable or medically necessary at this time. 
 
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 a Barostim Neo system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultraviolet therapy (96365, 97028) provided on March 16, 
2022 to March 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultraviolet therapy. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not pre-approved. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services.  
 
 
  
Therefore, we decided that the Plan does not have to pay for ultraviolet therapy (96365, 97028) provided on 
March 16, 2022 to March 31, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that the enrollee needs the 
requested services because she is in a lot of pain that is affecting her body. The Plan denied your request. The 
Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac (SI) joint in the setting 
of sacral joint dysfunction 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 radiofrequency ablation services. Our 
reviewer says that radiofrequency ablation services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure is considered experimental and investigational due to 
the wide variation in efficacy reported in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271, diphenhydramine (CPT 
code J1200), hydrocortisone sodium succinate (CPT code J1720), and methylprednisolone sodium succinate 
(CPT code J2930). 
 
You asked the Plan to pre-approve the medication. You say that the regimen is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation does support that the enrollee has had 
disease that has worsened or spread while on or following anti- PD-1/PD-L1 therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the use is prescribed until persistent or recurrent non-muscle invasive bladder cancer, disease 
progression, unacceptable toxicity, or (in patients without disease progression) for up to 24 months. This 
enrollee had recurrence treated May 1, 2022. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code J9271, diphenhydramine (CPT code J1200), hydrocortisone sodium 
succinate (CPT code J1720), and methylprednisolone sodium succinate (CPT code J2930).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the requested service is not supported for the first staging of prostate 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the 
PET scan is medically necessary. Our physician reviewer found the provided documentation indicates that the 
enrollee has unfavorable pathology and a very high prostate-specific antigen (PSA) level and is at high risk for 
metastatic disease. The reviewer found that traditional first-line imaging (bone scan and CT) have failed to 
show metastasis. Therefore, the reviewer found that the requested PET scan is medically reasonable and 
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 a PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 
attenuation correction and anatomical localization imaging (78815).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the member is non-compliant with home ventilator and does not want to use it. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. This patient has ALS. She has had a home 
ventilator for several years but is apparently not using it. The medical records are difficult to follow. But as 
recently as September 6, 2021, the patient was refusing the ventilator, and more recent documentation of 
ventilator need was not found. The most recent visit was February 25, 2022, a telehealth visit, and the 
ventilator was not mentioned. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from Acute Inpatient Rehab 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says that the 
enrollee can safely receive the services she needs 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cardiac arrest and 
diabetic ketoacidosis. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased 
from the out-of-network provider on September 26, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were purchased from an 
out-of-network provider. The Plan contract says that hearing aids ordered through providers other than the 
Plans network provider are not covered. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261 x 2) purchased from the out-of-network provider on September 26, 
2021.
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 records provided support the need or IRF care. 
The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower 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 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 surgical repair of a hip fracture after a fall. 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 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute surgical admission for bronchial valve surgery (CPT 
code(s): 31647 and 31651). 
 
You asked the Plan to pay for the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's doctor did not tell the Plan that the enrollee completed a pre-rehabilitation 
program, and the plan did not receive the results of special pictures of the enrollee's lungs (high-resolution CT 
scan). The Plan states the enrollee's doctor did not tell the Plan that they have no cardiac risk factors or that a 
cardiologist approved the enrollee for the procedure; therefore, the request is denied. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found EBV is considered not medically necessary because not all criteria have been met. This enrollee 
has severe chronic obstructive pulmonary disease (COPD) with hyperinflation and is being considered for EBV 
placement. The medical record does not document a high-resolution computerized tomography (CT) scan or an 
echocardiogram/cardiology evaluation. 
 
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 pay for acute surgical admission for bronchial valve surgery (CPT code(s): 31647 and 31651).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show the enrollee will need frequent care that 
cannot be adequately given in a less intensive setting. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH. 
 
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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac device monitoring services (93284) provided on 
October 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the monitoring services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the cardiac device monitoring services (93284) 
provided on October 24, 2021 by an out-of-network (OON) provider.