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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport and ground mileage provided on June 23, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the patient required transport from the skilled nursing facility to the doctor's office. The 
Plan denied your request. The Plan says after assessing the entire clinical situation, the information provided at 
the time of appeal does not support ambulance transport. 
 
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 service, basic life support, 
non-emergency transport and ground mileage. Our reviewer says that the ambulance transport services were 
not medically necessary. Our physician reviewer found the transportation via ambulance to and from a genitourinary appointment 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 service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport and ground mileage provided on June 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health skilled nursing services. 
 You asked the Plan to pre-approve home health services. You say that you disagree with the Plan's denial. 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 the enrollee 
has a past medical history of multiple medical comorbidities. Clinical documentation by most recent evaluation 
does not specify any new clinical concerns, wound care, medication changes thus the records do not show that 
skilled nursing services 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. Therefore, 13 additional home health skilled nursing visits are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home health skilled nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery. 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the vertiflex device is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has advanced non-small 
cell lung cancer (NSCLC). The use of Opdivo and Yervoy is not approved by the Food and Drug 
Administration (FDA) for this diagnosis. The National Comprehensive Cancer Network (NCCN) guidelines clearly state that if there is progression on a PD-1/PD-L1 inhibitor, using a PD-1/PD-L1 inhibitor is not 
recommended as a comment to ipilimumab and nivolumab. The use is not supported by the major drug 
compendia or clinical research that appears in a Medicare-approved medical journal. The drugs are therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo and Yervoy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for pathology services provided on April 4, 2022. 
 
You asked the Plan to hold you harmless for pathology services. You say that you are being billed for services 
which you believed would be covered by your Plan. The Plan denied your request. The Plan says that this claim 
cannot be paid as these services are incidental to other services provided on the same date. This means that 
these services were not billed/reported correctly and cannot be paid. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also say that Medicare health plans must make reasonable and diligent 
efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not clarified whether you were referred for pathology 
services by a contract provider. The file does not show that the Plan provided notice that pathology services 
would not be covered. In addition, the record shows that your appeal is being denied due to a billing error on 
the part of the provider. The Plan has not provided sufficient explanation of this error, including which service 
is incidental to which service (only one code is listed, and it is not clear if this is the service to which other 
services are incidental or vice versa). Regardless, a billing error on the part of a provider is not your 
responsibility as the enrollee. Therefore, we decided that the Plan has to hold you harmless for pathology 
services provided on April 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problems with low blood sugars (hypoglycemia) and is not treated with insulin. Based on this information, 
we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing for 16 hours. 
 
You asked the Plan to pre-approve neuropsychological testing for 16 hours. You say that the previous testing 
was not done in-depth. You also say that you think your memory is getting worse. The Plan denied your 
request. The Plan says the requested hours 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 neuropsychological testing for 16 
hours. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found it is unclear why you would require neuropsychological 
testing having had a recent bout of neuropsychological testing. Our reviewer also found that it appears 
redundant that you would undergo neuropsychological testing, and is therefore not considered medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing for 16 hours have not been met. Therefore, we 
decided that the Plan does not have to pre-approve neuropsychological testing for 16 hours.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided medical records to 
support payment. 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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Barostim Neo System (0266T, 
C1825). 
 
You asked the Plan to pre-approve the implantation of the Barostim Neo System. You say that the services are 
medically necessary. The Plan denied your request. The Plan says this device is considered experimental. 
 
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 implantation of the Barostim Neo 
System. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this device is considered experimental. 
 
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 implantation of the Barostim Neo System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the implantation of the Barostim Neo System (0266T, 
C1825).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection services identified with codes 64493 and 64494. 
 
You asked the Plan to pre-approve injection services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that injections are covered for certain indications. 
 
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 injection services. Our reviewer says 
that the documentation does support that the requested injection services are medically reasonable and 
necessary. Our physician reviewer found the enrollee has chronic low back pain. His pain also radiates to his 
foot. The enrollee had been treated previously with facet injections and had 80% relief for 2 months. On exam, 
his lumbar range of motion was noted to be normal, normal muscle tone and bulk in arms and legs. The 
enrollee was diagnosed with spondylosis with a plan to repeat the facet injections. The enrollee had bilateral 
facet injections on March 16, 2023. A second set of diagnostic facet blocks is medically reasonable and 
necessary. Therefore, the enrollee meets criteria for 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 injection services have been met. Therefore, we decided that the Plan has to pre-
approve injection services identified with codes 64493 and 64494.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the tests were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting.  Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on November 7, 2022.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the provider prescribed a ventilator to help the enrollee's breathing at 
various times of the day because of lung disease. Medicare does not cover ventilators used in this way. 
 
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 pulmonary graft-
versus-host disease related to leukemia treated with a bone marrow transplant in the past. Pulmonary function 
testing in 2020 showed moderate reduction in the FEV1. The enrollee has severe obesity with a BMI of 53.8. A 
recent arterial blood gas, done while stable, showed a pH of 7.40 and a PaCO2 of 47. Given that the enrollee's 
lung function impairment is not sufficient to account for CO2 retention, the enrollee most likely has obesity 
hypoventilation syndrome.  The enrollee may benefit from BiPAP during sleep. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. There is inadequate evidence that the Life2000 system is beneficial in the treatment of any 
chronic lung 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 15, 2022, 
through August 19, 2022, and billed with diagnosis code J96.01. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01 - Acute respiratory 
failure with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support secondary 
diagnosis code J96.01 - Acute respiratory failure with hypoxia. Our physician reviewer found the member 
presented with small cell lung cancer for chemotherapy and thoracentesis for pleural effusion. The member's 
respiratory rate was 18. The member was requiring low dose oxygen support with a 94 percent supplemental 
oxygen, had mild respiratory distress, was alert and oriented. The member was treated with Xanax, fluids, 
breathing treatments, and steroids with benefit. The member appeared to have a chronic obstructive pulmonary 
disease (COPD) exacerbation but not acute respiratory failure as there was no need for high flow oxygen 
support, bilevel positive airway pressure (BiPAP), or vent support. Therefore, the code, J96.01, acute 
respiratory failure with hypoxia was not sufficiently supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 15, 2022, through August 19, 2022, and billed with 
diagnosis code J96.01.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for left radiofrequency ablation (RFA), nerves innervating the 
sacroiliac joint, with image guidance (64625) provided November 29, 2022. 
 
You asked the Plan to pay for the RFA procedure. You say that you are attaching medical records and 
documents to support this claim for approval. Please review this appeal for reconsideration. The Plan denied your request. The Plan says radiofrequency ablation used for sacro-iliac joint pain is considered not medically 
necessary and investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
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 RFA 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 has chronic low back pain and underwent RFA of the lateral sacral branches on 
November 29, 2022. This is considered an experimental and investigational procedure because of the wide 
variation in efficacy reported in the literature. Therefore, the procedure was 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 the RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pay for left radiofrequency ablation (RFA), nerves innervating the sacroiliac joint, with image 
guidance (64625) provided November 29, 2022.