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

 
We decided that the Plan has to pay for ground mileage (A0425) and ambulance service, basic life support 
(bls), non-emergency transport, (A0428) provided on April 5, 2023. 
 
You asked the Plan to pay for ground mileage (A0425) and ambulance service, basic life support (bls), non-
emergency transport, (A0428). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says that this was denied because the details they received from the provider does not meet 
Medicare guidelines that show a medical reason the enrollee needs round trip non-emergency ambulance 
transportation and ground mileage. 
 
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 ground mileage (A0425) and ambulance 
service, basic life support (bls), non-emergency transport, (A0428). Our reviewer says that the request for 
ground mileage (A0425) and ambulance service, basic life support (bls), non-emergency transport, (A0428) 
meet the medical necessity criteria. Our physician reviewer found the enrollee is on 4 liters of nasal cannula 
(NC) at home and required oxygen during transport, which required medical personnel assisted during 
transportation. Our physician reviewer also found that the enrollee was weak and increased risk for fall, which 
also required assistance and higher level of care during the transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ground mileage (A0425) and ambulance service, basic life support (bls), non-
emergency transport, (A0428) have been met. Therefore, we decided that the Plan has to pay for ground 
mileage (A0425) and ambulance service, basic life support (bls), non-emergency transport, (A0428) provided 
on April 5, 2023.  
 
  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the stay for rehabilitation approved. 
The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be 
met at a lower level of care such as with home health services at home with supervision, in a long-term care 
facility, or with home health services in an assisted living facility.  
 
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 you are able sit to stand with moderate assistance, perform functional mobility with 
Rollator requiring moderate assistance, and able to walk to the bathroom with three rest breaks which is great 
improvement. This means that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ground mileage (A0425) and ambulance service, basic life support 
(bls), non-emergency transport, (A0428) provided on April 12, 2023. 
 
You asked the Plan to pay for ground mileage (A0425) and ambulance service, basic life support (bls), non-
emergency transport, (A0428). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says that this was denied because the details they received from the provider does not meet 
Medicare guidelines that show a medical reason the enrollee needs round trip non-emergency ambulance 
transportation and ground mileage. 
 
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 ground mileage (A0425) and ambulance 
service, basic life support (bls), non-emergency transport, (A0428). Our reviewer says that the request for 
ground mileage (A0425) and ambulance service, basic life support (bls), non-emergency transport, (A0428) 
meet the medical necessity criteria. Our physician reviewer found the enrollee is on 4 liters of nasal cannula 
(NC) at home and required oxygen during transport, which required medical personnel assisted during 
transportation. Our physician reviewer also found that the enrollee was weak and increased risk for fall, which 
also required assistance and higher level of care during the transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ground mileage (A0425) and Ambulance service, basic life support (bls), non-
emergency transport, (A0428) have not been met. Therefore, we decided that the Plan has to pay for ground 
mileage (A0425) and ambulance service, basic life support (bls), non-emergency transport, (A0428) provided 
on April 12, 2023.  
 
  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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied CT scan and that the services requested are medically necessary. The Plan denied 
your request. The Plan says that the criteria for a CT scan have not been met. 
 
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 pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found given the left bundle 
branch block and depressed left ventricular systolic function, the cardiac CT scan is a helpful prognostic tool 
for the enrollee to determine the amount of calcium as a marker of coronary artery disease. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary.  The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with altered mental status following a ground level fall. 
The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. 
The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 enrollee needs intense rehabilitation in order to 
not have long-term effects The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled care nursing facility.  
 
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 enrollee is medically stable requires standby assistance for bed mobility. The 
enrollee requires contact guard assistance for sit to stand transfers. The enrollee needs minimum assistance for 
basic activities of daily living and ambulation with a front-wheeled walker. This means that 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 does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT PNS. 
 
You asked the Plan to pre-approve SPRINT PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 SPRINT PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational therapy. 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 SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SPRINT PNS.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of sacral nerve stimulation versus a 
percutaneous implantation. 
 
You asked the Plan to pre-approve open implantation of sacral nerve stimulation versus a percutaneous 
implantation. You say that the requested open implantation of sacral nerve stimulation versus a percutaneous 
implantation is medically necessary. The Plan denied your request. The Plan says the requested open 
implantation of sacral nerve stimulation versus a percutaneous implantation 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 open implantation of sacral nerve 
stimulation versus a percutaneous implantation. Our reviewer says that the requested open implantation of 
sacral nerve stimulation versus a percutaneous implantation is not medically necessary. Our physician reviewer 
found the enrollee meets the above NCD criteria for percutaneous sacral nerve stimulator placement (64561) 
but not open sacral nerve stimulator placement (64581). There is no documentation as to why an open 
implantation is necessary versus a percutaneous implant as the trial placement was done with a percutaneous 
approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of sacral nerve stimulation versus a percutaneous 
implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve open 
implantation of sacral nerve stimulation versus a percutaneous implantation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PNS. 
 
You asked the Plan to pre-approve PNS. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit by Medicare for the member's condition. 
 
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 PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure that is the subject of ongoing 
clinical trials. 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 PNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve PNS.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 Home Health Skilled Nursing visits and 7 Home 
Health Physical Therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested 6 Home Health Skilled 
Nursing visits and 7 Home Health Physical Therapy visits are medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that appropriate skilled physical therapy goals have been met thus the records do not 
show that 7 additional home health skilled physical therapy visits are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. 
 
Clinical documentation does not specify any acute clinical status changes, changes in medication or plan of 
care thus the records do not show that 6 additional skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 Home Health Skilled Nursing visits and 7 Home Health Physical Therapy 
visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81001 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for the billed code. You say that physician's send specimens for testing. The Plan 
denied your request. The Plan says the accuracy of the billed service cannot be verified. 
 
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 81001 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, with microscopy. 
 
 
 We find that CPT code 81001 is not supported in the medical record. The records show that a urine culture was 
provided. There is a more applicable code to describe the testing provided. Based on this information, we 
decided that Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 81001 billed for date of service February 1, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided on 
March 25, 2023, to, March 26, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that the enrollee fell 
and broke their hip and was given the option of being moved into their bed without any medication or they can 
revoke hospice, receive medication and transport to the hospital. You say that the enrollee initially chose to 
move to the bed but was unable to handle the pain which made them quickly change their decision. 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 March 22, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
inpatient or observation care provided on March 25, 2023, to, March 26, 2023.