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

 
We decided that the Plan does not have to pre-approve vertebral corpectomy (vertebral body resection), partial 
or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment 
(63081). 
 
You asked the Plan to pre-approve vertebral corpectomy (vertebral body resection), partial or complete, 
anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment. 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 vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documented compression 
behind the vertebral body and the physical exam does not show weakness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebral corpectomy (vertebral body resection), partial or complete, anterior 
approach with decompression of spinal cord and/or nerve root(s); cervical, single segment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment (63081).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 
28, 2022, by an OON provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not 
authorized. 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 subsequent nursing facility care provided on 
November 28, 2022, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine 
(72148). 
 
You asked the Plan to pre-approve an MRI of lumbar spine. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation of six weeks of treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of lumbar spine. Our reviewer 
says that the requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. Our physician reviewer found the record provided does not indicate the 
presence of any red flag signs or symptoms and reveals a normal physical examination. The record provided 
does not document the failure of conservative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of lumbar spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine (72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a trial of conservative treatment. The magnetic 
resonance imaging corroborates other plausible causes of low back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on February 13, 2023, 
February 23, 2023, billed with procedure code 33361. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed without the clinical trial 
information. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under Coverage with Evidence 
Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care provided have not been met. We find that the clinical trial number was 
not reported on this claim as required. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital care provided on February 13, 2023, February 23, 2023, billed with procedure code 33361.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from June 21, 2022, to August 10, 
2022. 
 You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 21, 2022. The NOA was not received by the Plan until January 26, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from June 21, 2022, to August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH.  
 
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 does not require services at the LTACH that are not already available at 
the current facility. Transferring the enrollee to the LTACH is not medically necessary as it would not be 
clinically advantageous and as the enrollee is not yet stable for transfer 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve an electrical osteogenesis stimulator. You say that you are having surgery 
on August 8, 2023, and will need the device after surgery so you can walk. The Plan denied your request. The 
Plan says you do not meet the criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that an electrical osteogenesis stimulator is covered if you 
have a failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or following a 
multilevel spinal fusion surgery or following spinal fusion surgery where there is a history of a previously 
failed spinal fusion at the same site. 
 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 electrical osteogenesis stimulator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you were being treated 
for cervicalgia; radiculopathy of the cervical region; pain in the thoracic spine; intervertebral disc displacement 
of the lumbosacral region; radiculopathy of the lumbar region; and sacroiliitis not elsewhere classified. You 
presented with persistent low back pain. The exam is unchanged. Current peer-reviewed literature indicates that 
further large, randomized, controlled trials are required to support the use of electrical bone growth stimulators 
in the treatment of long-bone non-unions. Given the absence of large randomized controlled trials in the 
requested lumbar arthrodesis setting this request for the stimulator is not medically necessary for you. 
 
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 electrical osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical osteogenesis stimulator (E0748).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was called, but you were awake when they arrived, and said you would monitor your condition 
yourself without being taken to the hospital. You also say that a call to 911 was warranted for the situation, and 
you believe the cost of the ambulance should be covered. The Plan denied your request. The Plan says you 
received non-transport ambulance services on March 2, 2023, and this claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 2, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 20, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief.  The Plan denied your request. The Plan says the intracept procedure is 
considered investigational and 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 intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease or 
foraminal stenosis. Also, the cause of the back pain is not clear and therefore the intracept procedure is not 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625).  
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. 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 SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell, 
and the ambulance was called because you were trapped. You also say that the call was answered promptly, the 
equipment was removed quickly, you were examined, and no injuries were found. The Plan denied your 
request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there 
is no payable service. The Plan also says that as there was no transport, ambulance charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on December 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, Ondansetron Tab 8mg Odt oral. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the drug, Ondansetron Tab 
8mg Odt oral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the 
requested device is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval of the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of IRF 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 enrollee was admitted for osteomyelitis and amputation of a toe and was 
transferred to skilled nursing on July 4, 2023. 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 this 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial with 
supporting documentation. 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 the laboratory services 
provided on January 27, 2023.