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

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee is 
wheelchair bound and doesn't have anyone to provide transportation to dialysis. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for transportation by non-emergency ambulance. Additionally, 
transportation by stretcher is not covered under the routine transportation benefit 
 
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 pre-approve non-emergency ambulance 
transportation. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
the documentation does not support that other means of transport (such as a wheelchair van) were 
contraindicated for this enrollee. The documentation also does not support that the enrollee needs the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport for this non-emergent transport to scheduled dialysis. Therefore, the documentation does not support 
that the ambulance transport on is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an 
outpatient, if tolerance can be achieved. 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. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of shoulder rotator cuff. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation to support the need for the requested procedure. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of 
superior capsular release as an effective treatment. There was no evidence of any extenuating circumstances in 
this enrollee's specific case. Therefore, the requested right shoulder rotator cuff repair (superior capsular 
reconstruction), in this case, is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of shoulder rotator cuff.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95156 provided on August 31, 2022. 
 
You asked the Plan to pay for procedure code 95156. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the code billed is not supported in the provided documentation. 
 
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 95156 is multiple dose vials of non-venom antigens. 
 
We asked our coder 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 procedure code 95156. Our reviewer says that the records do 
not support the code billed. Our reviewer found the code requires the physician to provide supervision of the 
preparation and provision of the antigens for allergy immunotherapy. This is not documented in the records. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95156 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95156 provided on August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for npatient hospital care billed with diagnosis codes E87.2 and 
T79.6XXA rendered from March 18, 2022, to March 26, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly. The Plan denied your request. The Plan says secondary diagnosis codes E87.2 and 
T79.6XXA are not supported. 
 
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.   
 
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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the enrollee presented after an unwitnessed fall.  He had apparently 
struck his head and injured his thumb but was neurologically intact.  Initial laboratory studies revealed an 
elevated lactate, but a normal bicarb level and normal anion gap. There is no evidence of actual acidosis. Initial 
laboratory studies also revealed a mildly elevated creatine kinase (CK), but no evidence of traumatic muscle 
injury/ischemia. As such, the billing of E87.2 and T79.6 is not 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 npatient hospital care billed with diagnosis codes E87.2 and T79.6XXA rendered from March 18, 2022, to 
March 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 19, 2022, to 
April 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code A41.89 and secondary diagnosis code R65.20.  
The Plan denied your request. The Plan says the medical records do not support the billing of principal 
diagnosis code A41.89 and secondary diagnosis code R65.20.  
 
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 diagnosis codes A41.89 and R65.20. 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 medical records do not support the billing of principal diagnosis code A41.89 and 
secondary diagnosis code R65.20.  Our physician reviewer found the enrollee presented to the hospital on April 
19, 2022, with fever, cough, chest pain, a temperature of 99.2F with a pulse of 145/minute, blood pressure of 
126/79 and respirations of 19/minute with a room air pulse oximetry reading of 97%. At time of admission, the 
enrollee was not in acute distress. Mental status was at baseline. Laboratory studies were notable for 
leukocytosis, hyperglycemia, hypokalemia, and an elevated lactic acid. A chest X-ray showed no infiltrates or 
evidence of failure. Broad spectrum antibiotics were administered. The enrollee became hypotensive on April 
20, 2022. The enrollee was discharged on April 21, 2022, and was to complete a course of oral antibiotics. The 
medical documentation does not support that the enrollee in this case had a significantly dysregulated host 
response to infection.   
 
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 April 19, 2022, to April 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 would benefit from acute rehab to 
optimize level of functioning to return home. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 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. 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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found your resected tumor is peripheral (i.e. at the temporal tip) and therefore, the 
hippocampal exposure should be relatively and without a treatment plan, it is unclear what the exposure to the 
critical organs at risk including optic nerves and chiasm, hypothalamic-pituitary axis, brainstem (should be 
low), and cochlea (should be low) would be. To date, there is not enough data to support proton therapy for meningioma as an accepted standard for routine care, and the case records do not sufficiently demonstrate the 
need for proton therapy. Simply stating that proton therapy will reduce the dose to some normal tissues does 
not necessarily demonstrate that it is superior to intensity-modulated radiation therapy (IMRT), as the 
reductions should be clinically meaningful, and reduce toxicity risks in a clinically meaningful manner. 
Therefore, you do not meet 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 radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) rendered 
from October 2, 2021 through October 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 99232 remains not supported. 
 
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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity.  Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that no records from October 2, 2021 
have been identified. Therefore, CPT 99232 would not be supported for this date. Additionally, the records for 
10/4/2021 do not contain an expanded interval history or moderate complexity medical decision 
making.  Therefore, the billing of CPT 99232 on 10/4/2021 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99232) rendered from October 2, 2021 through 
October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80061, 82977, 84480) provided on August 25, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80061, 82977, 84480) provided on August 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22515, 22514). 
 
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that both PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
from May 26, 2023, corroborates a mild-to-moderate compression deformity of L2, which appears acute. 
However, the MRI also notes that there is mild posterior superior retropulsion and mild retrolisthesis of L1 on 
L2. Retropulsion is a relative contraindication for the requested kyphoplasty. Moreover, the back pain cannot 
be concluded to be primarily due to the acute compression fracture (as other pathology is evident at this level). 
Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22515, 22514).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve Heelex radiation treatment (low dose radiation therapy). 
 
You asked the Plan to pre-approve Heelex radiation treatment (low dose radiation therapy). 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 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 Heelex radiation treatment (low dose 
radiation therapy). 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 osteoarthritis in the left foot. The 
documentation describes conventional treatments are not working well and the enrollee was referred to the 
radiation oncologist by a podiatrist. Radiation for treatment-resistant osteoarthritis, based upon published 
literature and guideline statements (from Germany) would be considered to be furnished with accordance of 
accepted standards of care and 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 Heelex radiation treatment (low dose radiation therapy) have not been met. 
Therefore, we decided that the Plan has to pre-approve Heelex radiation treatment (low dose radiation therapy).  
 
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 PVA procedure (22513). 
 
You asked the Plan to pre-approve a PVA. You say that the requested service is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PVA. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident in the case record regarding severe pain that is worsening, or 
stable with a progression of the vertebral height reduction, kyphotic deformity or severe impact on the 
enrollee's daily functioning. The enrollee has not had testing for osteoporosis evaluation. Additionally, there are 
other plausible causes for the enrollee's 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 a PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a PVA procedure (22513).