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

 
We decided that the Plan does not have to pre-approve 3 level lumbar laminectomy (63048, 63047). 
 
You asked the Plan to pre-approve 3 level lumbar laminectomy. 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 3 level lumbar laminectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested 3-level lumbar 
laminectomy is not medically reasonable or 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 3 level lumbar laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 3 level lumbar laminectomy (63048, 63047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic 
compressor, half leg (E0669) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and a half leg segmental pneumatic appliance 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 
a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental 
pneumatic appliance for use with pneumatic compressor, half leg (E0669) to be provided by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 27, 2023. 
 
You asked the Plan to pay for the ambulance transport services and ground mileage. You say that the medical 
records support the need for the ambulance transport services. The Plan denied your request. The Plan says the 
Medicare rules for coverage of the non-emergency ambulance transportation and ground mileage have not been 
met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance transport services and ground 
mileage. Our reviewer says that the ambulance transport services were not medically necessary. 
 Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's living facility 
was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport services and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of a home ventilator for 3 months.  
 
You asked the Plan to pre-approve a continuation of a home ventilator. You say that the records provided 
support the need for continued use of a home ventilator.  The Plan denied your request. The Plan says that the 
enrollee will be using the home mechanical ventilator in a BiPAP mode. The Plan says that payment for a 
portable ventilator to deliver ventilatory support via CPAP settings is inconsistent with Medicare coverage 
rules. The Plan says that continued use of CPAP may be considered. 
 
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 continuation of a home ventilator for 
3 months. Our reviewer says that a continuation of a home ventilator for 3 months is medically reasonable and 
necessary. Our physician reviewer found the enrollee has severe COPD and is on a narcotic for chronic pain.  
The enrollee has had a home ventilator since December 2022.  Clinical notes indicate the enrollee had a partial 
pressure of carbon dioxide (PaCO2) of 50, although the details and context are not provided.  Pulmonary 
function testing in 2021 showed a forced expiratory volume in one second (FEV1) of 17% of predicted with an 
obstructive pattern.  A compliance report covering February 7, 2023, to May 7, 2023, shows consistent use of 
the device, but it is being used in the CPAP mode.  A separate record on the ventilator from March 2023 
indicates use in the average volume assured pressure support (AVAPS)-auto expiratory (AE) mode.  The 
records do not show that the enrollee has been tried on CPAP or BiPAP with AVAPS as an outpatient. The 
current device should be approved for another 3 months to allow time for transition to 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 continuation of a home ventilator for 3 months have been met. Therefore, we 
decided that the Plan has to pre-approve a continuation of a home ventilator for 3 months.   
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on May 27, 2022. 
 
You asked the Plan to pay for the ambulance transport service and ground mileage. You say that the claim 
denied as should be paid by the liability carrier. The Plan denied your request. The Plan says the auto insurance 
carrier has paid the full amount so there is nothing left for the Plan to pay. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan's allowed amount 
is $406.69. Combined, the auto carrier payment and the Plan's payment should not exceed our normal 
allowable amount. The Plan has confirmed with the auto insurance carrier that they have paid $599.01. As the 
secondary insurer, the Plan cannot be held responsible for the ambulance transport service and ground mileage 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for ambulance service, basic life support, non-emergency transport and ground mileage provided 
on May 27, 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 you are in pain and require IRF care. The Plan 
denied your request. The Plan says IRF care is not medically necessary. 
 
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 do not have complex nursing or rehabilitation needs. 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 you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code S2900. 
 
You asked the Plan to pre-approve procedure code S2900. You say that the service is necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S2900.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT perfusion study provided on January 29, 2023. 
 
You asked the Plan to pay for the CT perfusion study. You say that this study is an essential tool in identifying 
ischemia. The Plan denied your request. The Plan says there is no documentation of an acute ischemic stroke 
caused by unilateral large vessel occlusion in the proximal anterior circulation. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 pay for the CT perfusion study. Our reviewer says 
that this study was not medically necessary. Our physician reviewer found that the computed tomography 
angiogram (CTA) of the brain performed on January 29, 2023, showed no large vessel occlusion, which would 
be amenable to therapy.  
 
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 CT perfusion study have not been met. Therefore, we decided that the Plan 
does not have to pay for the CT perfusion study provided on January 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint (64625). 
 
You asked the Plan to pre-approve RFA of the SI joint. 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 RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SI joint RFA is experimental 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint (64625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee requires this device due to 
worsening heart failure. The Plan denied your request. The Plan says the CardioMEMS device is considered 
unproven and 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a lack of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you say that you need the 10 
additional trips to go to your cardiologist appointments. The Plan denied your request. The Plan says your 
benefit plan does not cover more than 10 one way trips per plan year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 10 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 10 additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging and a specialist office visit 
provided on May 10, 2022, to November 23, 2022. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging and a specialist office visit. You say that you did 
not receive a bill for May 10, 2022, so you assumed the Plan paid it. You also say you returned for a followup 
six months later. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmic diagnostic 
imaging and a specialist office visit provided on May 10, 2022, to November 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency 
transport, and ground mileage provided on August 20, 2022. 
 You asked the Plan to pay for the ambulance transport service and ground mileage. You say that you are 
requesting to reconsider the claim for payment and to review the submitted records. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 20, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance service, 
advanced life support, emergency transport, and ground mileage provided on August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
March 06, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you went in for a 
routine eye examination with a $0 copayment. 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered examination (diagnosis and treatment for diseases and conditions of the eye). 
 
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the Medicare-covered examination (diagnosis and treatment for diseases and conditions of the eye) benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a medical eye examination provided on March 
06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. Although it may be helpful to monitor per and post meal blood sugars. 
There are likely little benefit garners from 6 times a day check with the fingerstick method or a CGM in an 
enrollee with A1c of 5.3. The enrollee is not using insulin and not having lows that we are told of, so the CGM 
criteria are not 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the records provided support the 
need for the requested device.  The Plan denied your request. The Plan says the item in dispute 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 mechanical ventilator. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found a home ventilator 
is not medically necessary.  This enrollee has obstructive sleep apnea and multiple sclerosis.  There is no 
diagnosis of COPD, thoracic restrictive disease, or other neuromuscular disease.  An arterial blood gas on May 
11, 2023, done as an outpatient, showed mild compensated carbon dioxide (CO2) retention.  The etiology of 
this is unclear.  There are no pulmonary function tests or other documentation of diaphragmatic weakness.  It is 
unclear if the multiple sclerosis is severe enough to be associated with respiratory failure.  The enrollee may 
benefit from BiPAP during sleep.  The records do not show that this has been tried. 
 
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 mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).