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

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on July 23, 2022. 
 You asked the Plan to pay for the services. You say that the enrollee required emergent transfer to lung 
transplant services not available at the transferring facility. The Plan denied your request. The Plan says the 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not sufficiently support that the enrollee suffers from an illness or injury that 
contraindicates transportation by any means other than ambulance. The documentation also does not 
sufficiently support that the patient's condition was such that the time needed to transport a patient by ground, 
or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the 
patient's health. The documentation did not support that the transferring hospital did not have adequate 
facilities to provide the medical services needed by the patient at the time of transfer. 
 
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 the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on July 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 7, 
2023.  
 
You asked the Plan to pay for procedure code 88341. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 17 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 7, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that the requested drug is necessary for the enrollee's 
treatment.  The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Stelara. 
 
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 Entyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Stelara. The reviewer also found that the documentation 
does not support that Stelara would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the reviewer found that the step therapy criteria 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic product (0627T). 
 
You asked the Plan to pre-approve a percutaneous injection of allogeneic product. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services are 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 a percutaneous injection of allogeneic 
product. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case.  Our physician reviewer found that the requested service is purely experimental. There is no peer-
reviewed clinical research to adequately support the 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 a percutaneous injection of allogeneic product have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic product (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's quality of life would be 
improved with use of NIV therapy. Without NIV therapy, the enrollee is at risk for more costly procedures and 
further hospital admissions. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in Volume Targeted PS mode that could be delivered by BiPAP is not covered. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
bronchiectasis. The enrollee was recently hospitalized with an exacerbation and ABG was consistent with acute 
on chronic hypercarbic respiratory failure. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease.  This enrollee may benefit from BiPAP with AVAPS during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiological monitoring provided for the month 
ending on November 22, 2022, billed with four units of code 99458. 
 
You asked the Plan to pay for the services as billed. You say that this was correctly billed and should be paid.  
The Plan denied your request. The Plan says there is not sufficient evidence to support the necessity of 
exceeding the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
The MUE for CPT code 99458 is 3 units. The MAI value for this code is 3. You billed 4 units, exceeding the 
MUE.  
 
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 as billed. Our reviewer says that 
the documentation does not support the additional unit in excess of the MUE.  Our physician reviewer found 
the enrollee is a female with a history of diabetes controlled with medications including insulin. Together with 
the primary code, the MUE allows for 80 minutes in a month for these services, and an additional 20 minutes 
were billed. In this case, the reviewed documentation did not include evidence that the additional time was 
medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the remote physiological monitoring provided for the month ending on November 22, 
2022, billed with four units of code 99458.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief and meets all five criteria for the requested procedure. The Plan denied 
your request. The Plan says the request is 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee's records include imaging studies that show other causes of back pain. 
The MRI shows facet djd and disc herniations. The cause of back pain is not clear with the provided records. 
 
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 a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (64640). 
 
You asked the Plan to pre-approve an injection treatment. You say that the requested it is medically necessary 
The Plan denied your request. The Plan says this type of treatment is considered experimental and/or 
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 an injection treatment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee has chronic left knee pain due to osteoarthritis. She has tried NSAIDs, a 
home exercise program and steroid injections. She does not want a surgical intervention. The role of neurolysis 
of the genicular nerves for treatment of osteoarthritis without surgical intervention is the subject of ongoing 
clinical trials. It is considered experimental at this time.  Therefore, the request is deemed not 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 an injection treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (64640).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device will help you recover at home 
and will prevent you from having to return to the hospital multiple times to be intubated. The Plan denied your 
request. The Plan says Medicare guidelines say home ventilators are not reasonable and necessary when the 
sole purpose of the home NIV is to function as a respiratory assist device. The request is not medically 
necessary. 
 
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 the service is not medically necessary. Our physician reviewer found you have severe 
tracheobronchomalacia and severe anxiety. You have had multiple hospitalizations and intubations related to 
attacks of severe anxiety and airway collapse. Positive pressure ventilation was recently prescribed to use 
during these attacks. There is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular 
disease. There is no evidence of chronic CO2 retention. The ventilator is ordered to be used at settings that can 
be provided with BiPAP.  Medicare does not cover a home ventilator for your diagnosis, or when used at 
settings that can be provided with BiPAP.  
 
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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device at this point should only be approved for patients enrolled 
in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a clinical trial of the 
device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E1399) (extracorporeal 
shockwave therapy to treat erectile dysfunction (ED)) provided on January 13, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this claim cannot be reprocessed for payment until a corrected claim is received. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
extracorporeal shockwave therapy for the treatment of erectile dysfunction is considered 
experimental/investigational. There is limited long-term data on the safety and efficacy of this treatment. The 
American Urological Association (AUA) has not yet made a formal recommendation on the use of shockwave therapy for erectile dysfunction. However, the AUA has expressed concern about the marketing and delivery of 
these therapies. 
 
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 the durable medical equipment (E1399) (extracorporeal shockwave therapy to treat erectile 
dysfunction (ED)) provided on January 13, 2022.
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 you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the request for a SNF admission is 
not medically necessary.  
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical removal of instrumentation (22852). 
 
You asked the Plan to pre-approve a removal of instrumentation. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 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 a removal of instrumentation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found that there has not been an anesthetic block performed to see if the hardware at 
issue is painful. More testing is needed to demonstrate the medical necessity of the requested 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 a removal of instrumentation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a surgical removal of instrumentation (22852).
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 office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that you are requesting an expedited 
reconsideration stating this is an important health condition that needs to be evaluated due to family history and 
your health. The Plan denied your request. The Plan says imaging to measure the amount of calcium deposits is 
not a covered service and will be denied as 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve quantitative calcium scoring.