Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) physical therapy (PT) home health visits 
(G0151). 
 
You asked the Plan to pre-approve home health services. You say that the enrollee will benefit from continuing 
the physical therapy (PT) visits which will allow him to gain more strength and will lower his fall risk. 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 clinical 
documentation shows that the enrollee has benefitted from home health physical therapy. However, updated 
notes do not specify any additional skilled need to complete stated home health physical therapy goals (such as 
endurance) thus the records do not show that 5 additional home health skilled physical therapy visits are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
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 five (5) physical therapy (PT) home health visits (G0151).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on February 20, 2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that the medical records provided 
support the need for the requested ambulance transport. The Plan denied your request. The Plan says the 
ambulance transport was not medically necessary.  
 
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 transport services. Our 
reviewer says that the ambulance transport services were not medically necessary. Our physician reviewer 
found there was no indication to use this mode of transportation. The enrollee was asymptomatic, has a 
Glasgow Coma Scale (GCS) of 15, and was able to stand/walk without assistance.  Alternative modes of transportation were not contraindicated. 
 
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 transport services have not been met. Therefore, we decided that 
the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, and ground 
mileage provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker purchased on March 22, 2023. 
 
You asked the Plan to pay for the walker. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker purchased on March 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is considered experimental for knee 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 the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for the billed code. You say that supporting documentation was provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 The file shows that code 99153 was provided in an outpatient hospital facility. We find that payment for code 
99153 is not supported. Specifically, there is no separate payment to the physician for code 99153 when 
performed in the facility setting. Therefore, we decided that the Plan does not have to pay for procedure code 
99153 billed for date of service March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service March 28, 
2023. 
 
You asked the Plan to pay for the billed service. You say that you are not affiliated with the facility. The Plan 
denied your request. The Plan says outpatient codes are not payable as inpatient services. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making.  
 
We find that CPT code 99205 is not supported in the medical record. The documentation shows that the 
enrollee was receiving inpatient care at the time the services at issue were provided. The facility must furnish 
all necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Based on this information, we decided that Medicare rules for coverage of the billed service have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99205 billed for date of 
service March 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is independent with mobility and does not require the 
services of a skilled therapist for continued strengthening exercises, which can be done with a home exercise 
program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer 
treatment (E0766). 
 
You asked the Plan to pre-approve an electrical stimulation device. 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 tumor treatment field therapy (E0766) is covered for 
the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when certain 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 an electrical stimulation device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in the most recent 
NCCN guidelines for the upfront adjuvant treatment of glioblastoma, alternating electric field therapy has a 
category 1 recommendation only for those patients with supratentorial disease. The LCD criteria (reflecting 
who would be eligible for the EF14 study) are not 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 an electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electrical stimulation device used for cancer treatment (E0766).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization of the knee (36247 and 
36246). 
 
You asked the Plan to pre-approve genicular artery embolization of the knee (36247 and 36246). You say that 
the requested genicular artery embolization of the knee (36247 and 36246) is medically necessary. The Plan 
denied your request. The Plan says the requested genicular artery embolization of the knee (36247 and 36246) 
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 genicular artery embolization of the 
knee (36247 and 36246). Our reviewer says that the requested genicular artery embolization of the knee (36247 
and 36246) is not medically necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. There is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization of the knee (36247 and 36246) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genicular artery embolization of the knee 
(36247 and 36246).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you for the office visits provided by Provider 2. We decided that the 
Plan does not have to reimburse you for the office visits provided by Provider 1.  
 You asked the Plan to reimburse you for the office visits provided from April 19, 2022, to March 27, 2023, 
performed by David Shaw, MD (Provider 1), and Paul Lynn, MD (Provider 2). You say that the providers will 
not send the claims to your Plan. You say that they have billed Original Medicare. The Plan says that the 
providers in this case have opted out of Medicare. The Plan also says that payment cannot be made to providers 
that have opted out of Medicare. 
 
We decided that the Plan has to reimburse you for the office visits provided by Provider 2.  
 
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. Specifically, the Plan has not supported their denial reason that Provider 1 is 
non-contracted with Medicare. Our research shows that Provider 1 is contracted with Medicare. Therefore, we 
decided that the Plan has to reimburse you for the office visits provided by Provider 2.  
 
We also decided that the Plan does not have to reimburse you for the office visits provided by Provider 1. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the office visits provided by 
Provider 1. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on Medicare guidelines, the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. The Plan denied 
your request. The Plan says you need a higher level of care and it would be detrimental to recovery and safety 
if you are not able to receive services at the inpatient rehabilitation facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of your nursing medical and rehabilitation needs does require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You were admitted to the hospital on November 
3, 2023 for a right knee arthroplasty. Although you primarily underwent a knee arthroplasty, you would benefit 
from the oversight of a rehabilitation physician and rehabilitation nursing care given the complexity of your 
medical history, which includes diabetes mellitus, Parkinsons Disease, stroke, hypertension, atrial fibrillation, 
hyperlipidemia, and deep venous thrombosis. Your medical and rehabilitation needs do require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. You also require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program at least three hours a day and five days a week, or 15 hours over seven consecutive days. You have 
had a significant decline in function and mobility. You require the intensity of therapies provided on acute 
inpatient rehabilitation, including physical and occupational therapies. Therefore, the acute inpatient 
rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 June 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that the provider chose to send the test to the lab to 
device a treatment plan. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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 June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found there is no 
Magnetic Resonance Imaging (MRI) showing only modic changes without facet degenerative joint disease 
(DJD) or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on April 5, 2023. 
 
You asked the Plan to pay for the ambulance transport services. You say that this service should be paid. The 
Plan denied your request. The Plan says that the clinical information provided does not show the enrollee meets 
criteria for this type of transportation. 
 
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 transport services. Our 
reviewer says that the ambulance transport services were medically necessary. Our physician reviewer found 
the enrollee is on 4L nasal cannula at home and required oxygen during transport. Medical personnel assisted 
in transferring nasal cannula to portable supply. It was also noted that the enrollee has a history of generalized 
weakness and is at increased risk for falls and required assistance. Therefore, the enrollee required higher level 
of care during transport and the ambulance transport meets medical necessity. 
 
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 transport services have not been met. Therefore, we decided that 
the Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground mileage 
provided on April 5, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 You asked the Plan to pre-approve Avastin. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug does not meet the step 
therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Avastin. Our reviewer says that the 
drug requested does not meet the step therapy requirements to be approved. Our physician reviewer found the 
requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed 
Mvasi, the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. The 
requested service cannot be recommended as the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.