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

 
We decided that the Plan does not have to pay for procedure code 70498 billed for June 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 70498 has an OPPS status indicator of Q3(S). This code has no separate payment. Therefore, we decided that the Plan does not have to pay for procedure 
code 70498 billed for June 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azelastine spray. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Azelastine spray.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 enrollee's current needs cannot be 
met at a lower level of care, and clearly meets LTACH criteria.  The Plan denied your request. The Plan says 
the LTACH is not medically necessary, and the enrollee's needs can be met at a lower level of care such as an 
acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.  
 
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 pneumonia. 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 he is not currently receiving but that would be available at the LTACH facility.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve a Sprint PNS system. 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 a Sprint PNS system. 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 therapy for low back pain. 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 a Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system (64555).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the hearing aids provided on April 14, 2023. 
 
 
You asked the Plan to pay more for the hearing aids. You say that you should be reimbursed more for the 
hearing aids.  You say you should be reimbursed a total of $1,999 and were only reimbursed $1,060. The Plan 
denied your request. The Plan says that the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules 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. We find that the Plan did not submit documentation showing the allowed 
amounts for the hearing aids. This means we are unable to determine if the Plan has paid the correct amount.  
Therefore, we decided that the Plan has to pay more for the hearing aids provided on April 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary implantable nitinol device (iTIND) (55899, 
C9769). 
 
You asked the Plan to pre-approve an iTIND. 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 an iTIND. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found iTIND is not medically reasonable and necessary in this case. The 2023 AUA Guideline update 
regarding iTIND states: iTind is an effective treatment option for men with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) who are not candidates for or who have not responded to 
medication or other minimally invasive therapies. The records do not show that the enrollee is not a candidate 
for other minimally invasive therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an iTIND have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a temporary implantable nitinol device (iTIND) (55899, C9769).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (37242). 
 
You asked the Plan to pre-approve prostate artery embolization. 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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostate artery embolization is not medically reasonable and necessary in 
this case. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization (37242).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar spine magnetic resonance imaging (MRI).  
 
You asked the Plan to pre-approve the lumbar spine MRI. You say that your doctor diagnosed you with lumbar 
disc disease and wants to perform an MRI. The Plan denied your request. The Plan says the lumbar spine MRI 
is not medically necessary. The Plan says the enrollee does not show red flag conditions and records do not 
show the back pain has been present for a month and has not responded to at least four weeks of conservative 
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 the lumbar spine MRI. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you have diabetes mellitus and 
peripheral neuropathy. The record shows you have a two-week history of low back pain and no red flag to 
mandate immediate MRI without first trying a six-week trial of physical 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 lumbar spine MRI.  have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the lumbar spine magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheterization (93458). 
 
You asked the Plan to pre-approve a cardiac catheterization. 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 a cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support a need for invasive cardiac catheterization in this setting. 
As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in 
this enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheterization (93458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) (64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee is having pain that interferes with 
activities of daily living, and the requested procedure is for long-term pain relief. The appellant says the 
enrollee has had two successful injections and the RFA is the next step in the enrollee's care plan.  The Plan 
denied your request. The Plan says the radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has sacroiliitis and has had diagnostic blocks which produced 80% pain relief. 
Radiofrequency ablation of the sacroiliac (SI) joint is considered experimental due to the wide variation in efficacy reported in the peer reviewed literature. 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation (RFA) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) at a tertiary level of care. 
 
You asked the Plan to pre-approve an office visit at a tertiary level of care. You say that the service is 
medically necessary. The Plan denied your request. The Plan says available medical records do not state 
medical reasons why member needs to be seen by highly specialized tertiary provider nor why member cannot 
be cared for by available in-network community specialist. 
 
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. 
 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 office visit with a tertiary provider. 
Our physician reviewer says that it is not medically necessary to receive this service at a tertiary level of care. 
Our physician reviewer found that the enrollee is not in need of any specific care that cannot be offered at a 
community level of care. 
 
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 
an office visit (99204) at a tertiary level of care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Ipilimumab. 
 
You asked the Plan to pre-approve Opdivo and Ipilimumab. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Opdivo and Ipilimumab. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the requested use of Opdivo 
and Ipilimumab is not FDA-approved for the enrollees diagnosis. This is not for first line therapy and the 
enrollee has progressed on prior immunotherapy. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Ipilimumab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Ipilimumab.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, conventional air services, transport, one way (rotary 
wing), and rotary wing air mileage provided on December 12, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that the travel time was significantly 
reduced using the air ambulance. This was necessary given the enrollee was critically ill. The Plan denied your 
request. The Plan says that the information provided does not support criteria for air ambulance transport and 
there are multiple closer facilities with appropriate services to treat the enrollee.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer 
says that the air ambulance services were medically necessary. Our physician reviewer found utilizing the air 
ambulance transfer decreased the out of hospital transfer time to 1 hour and 17 minutes versus 3 hours and 52 
minutes by ground transfer. The enrollee was in septic shock and required titration of levophed in route. The 
enrollee was at high risk of decompensation during transport and the transferring hospital did not have urology 
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 the air ambulance services have been met. Therefore, we decided that the Plan 
has to pay for ambulance service, conventional air services, transport, one way (rotary wing), and rotary wing 
air mileage provided on December 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on June 12, 
2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says Medicare guidelines say that 
this item or service is covered with either a diagnosis of renal disease or diabetes.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on June 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 27, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
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 nursing facility care provided on June 27, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says that facet joint 
injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the injections. Our reviewer says that 
facet joint injections are medically necessary. Our physician reviewer found that you are doing a home exercise 
program with an order for physical therapy. Therefore, the request is 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 injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found vertiflex is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.