Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of acute rehabilitation services. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for services in an IRF. 
 
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 do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Td vaccine and administration provided on April 20, 
2023.  
 
You asked the Plan to pay for the Td vaccine and administration. You say that the vaccine should be covered. 
The Plan denied your request. The Plan says the vaccine you received is not covered by the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Td vaccine and 
administration. The Plan follows the same rules.  
 
The records do not show that you were injured or directly exposed to any illness related to the Td vaccine when 
the vaccine was received. Therefore, we decided that the Plan does not have to pay for the Td vaccine and 
administration provided on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on February 
16, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on February 16, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walk-in shower installation (A9999), provided on August 
28, 2021. 
 
You asked the Plan to pay for the walk-in shower installation. You say that the item should be covered. The 
Plan denied your request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the walk-in shower installation was not filed until March 7, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the walk-in shower installation (A9999), provided on August 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a spinal distraction device. 
 
You asked the Plan to pre-approve the insertion of a spinal distraction device. You say that the enrollee is in 
severe pain, and it is progressively getting worse. The Plan denied your request. The Plan says the insertion of 
a spinal distraction device 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 Insertion of a spinal distraction 
device. Our reviewer says that the insertion of a spinal distraction device is not medically necessary. Our 
physician reviewer found that distraction devices in the spine are experimental at this time for the treatment of 
spinal stenosis. 
 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 Insertion of a spinal distraction device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a spinal distraction device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on March 20, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an eye exam. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 an eye exam provided on March 20, 2023, by an 
OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
25, 2022.  
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99285 is bundled into 
payment for code 99291. 
 
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, we have confirmed that code 99285 is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99285 billed for date of service September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 
29, 2022. 
 You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99223 is bundled into 
payment for code 44320. 
 
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, we have confirmed that code 99223 
is a column II code to column I code 44320. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635) and destruction by neurolytic 
agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, each additional facet joint 
(64636). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you need the requested 
procedure to improve quality of daily routines. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show you do not have records indicating how long you benefited from 
two diagnostic MBB yielding 80% or better improvement in your pain. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found according to the coverage criteria, a repeat thermal facet joint RFA at the 
same anatomic site is considered medically reasonable and necessary provided you have a minimum of 
consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living (ADLs) as compared to baseline 
measurement using the same scale. If there is an extended time, two (2) years or more since the last RFA 
and/or there is a question as to the source of the recurrent pain then diagnostic (testing) procedures must be 
repeated. In this case, there is no documentation of the duration of pain relief after the RFA on February 7, 
2020. In addition, it has been more than two years since the last RFA at the same location. The review has 
determined that you do not meet criteria for the requested procedure. The RFA 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance; lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, each additional facet joint (64636).
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 without the requested therapy, this enrollee 
is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested device. 
 
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 COPD, severe 
obesity, obstructive sleep apnea, obesity hypoventilation syndrome, and heart failure with preserved ejection 
fraction (HFpEF). The enrollee was hospitalized in July with a urinary tract infection, sepsis, pneumonia, 
pulmonary edema, and arterial blood gas (ABG) consistent with acute on chronic hypercarbic respiratory 
failure. The enrollee improved clinically on bilevel positive airway pressure (BiPAP). There are no pulmonary 
function tests to assess the severity of the COPD. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. There is no ABG done while stable to document chronic carbon dioxide (CO2) 
retention.  If that is present, the enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep as an outpatient. There is no documentation that this has been tried and shown 
to fail as an outpatient. Medicare does not cover a home ventilator 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted surgeon services provided by Saran Rosner, M.D., 
on September 12, 2022. 
 
You asked the Plan to pay for assisted surgeon services. You say that the surgeon needed assistance during the 
approved procedure. The assisted surgeon services were medically necessary. The Plan denied your request. 
The Plan says the assistant surgeon has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for assisted 
surgeon services provided by Saran Rosner, M.D., on September 12, 2022.
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 is bedridden and only four days post-
surgery of the femur. You say if the enrollee gets rehabilitation, they will be able to gain the mobility they need 
to be more independent. The Plan denied your request. The Plan says the IRF services requested 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 do 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 physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you do not agree with the denial for the 
requested physical therapy. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
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. 
 
  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 
physical therapy to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device (E1399). 
 
You asked the Plan to pre-approve a Volara device. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says safety of long-term use of VolaraTM in the home setting 
has not been established. Use of the VolaraTM Device in the in-home setting is therefore considered 
experimental/investigational. 
 
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 Volara device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Volara system-high frequency oscillation lung expansion device has not been proven to be 
superior to other airway clearance devices. The enrollee also has a drug resistant chronic infection which can 
precipitate further chronic infection and hence more secretions and plugging. The enrollee has mucous 
plugging, and an unproven device (Volara system) is uncertain to improve progression of her disease or 
mucous plugging or symptoms. 
 
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 Volara device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara system-high frequency oscillation lung expansion device (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case there was no mention of FTD. 
FTD was not otherwise suspected. The NCD also does not cover PET for use in other forms of dementia (such 
as that from alcohol abuse). In as much the requirements of the NCD would not have been met. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ferritin (82728), hemoglobin; glycosylated (A1C) 
(83036), thyroid stimulating hormone (TSH) (84443), and blood count; complete (CBC) (85025) testing 
provided on December 9, 2022. 
 
You asked the Plan to pay for the ferritin, A1C, TSH and CBC testing. The Plan denied your request. The Plan 
says this testing is not covered because it was provided for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Ferritin, A1C, TSH and CBC testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the ferritin (82728), hemoglobin; glycosylated (A1C) (83036), thyroid stimulating 
hormone (TSH) (84443), and blood count; complete (CBC) (85025) testing provided on December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac joint (SIJ) 
(64625). 
 
You asked the Plan to pre-approve RFA for the SIJ. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this service is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint (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 RFA for the SIJ have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) for sacroiliac joint (SIJ) (64625).