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

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425, 
A0382). 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee is stable and at home. The enrollee does 
not need basic or advance life support during the transportation. The enrollee does not need ambulance 
transportation. The enrollee can go by other means of transportation such as routine transportation with 
wheelchair or stretcher van. 
 
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 services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation can be provided by other means without endangering the enrollee's 
condition. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425, A0382).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment - includes modification and 
placement (D6056) and an abutment supported porcelain/ceramic crown (D6058).  
 
You asked the Plan to pre-approve a prefabricated abutment - includes modification and placement (D6056) 
and an abutment supported porcelain/ceramic crown (D6058). You say that you went to the dentist over a 
crown that broke 3 to 4 months ago, and the dentist ground the rough edges. You also say that now you have to 
use the right side of the mouth, therefore putting pressure on the back teeth. The Plan denied your request. The 
Plan says your dentist's notes/x-rays do not show it is needed for a procedure to place, remove or treat an 
implant. Please check with your dentist for other options. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
prefabricated abutment - includes modification and placement (D6056) and an abutment supported 
porcelain/ceramic crown (D6058) when the services are medically necessary and reasonable.  
 
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 prefabricated abutment - includes 
modification and placement (D6056) and an abutment supported porcelain/ceramic crown (D6058). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there was no narrative 
indicating that a replacement of the abutment and crown were needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a prefabricated abutment - includes modification and placement (D6056) and an 
abutment supported porcelain/ceramic crown (D6058) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prefabricated abutment - includes modification and placement (D6056) and an 
abutment supported porcelain/ceramic crown (D6058).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. There is no compelling rationale presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception.  
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 (64628, 64629).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on May 25, 2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the provider is ineligible to bill Medicare. 
 
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 specific denial rationale provided by the Plan is not supported. 
We have verified that the provider is listed as enrolled with Medicare on the date of service in question. As 
such, denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for practitioner 
services provided on May 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered item or service, private transportation 
(A9270) provided October 4, 2022, to October 7, 2022. 
 
You asked the Plan to pay for the non-covered item or service. You say that you were only able to return home 
by renting a vehicle and having a friend with emergency medical technicians (EMT) training to drive you from 
Long Beach to Oregon. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked the file and Medicare rules. The claim was billed with the non-covered code A9720. Private 
transportation is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the non-covered item or service have not been met. Therefore, we decided that the Plan does not have to pay 
for the non-covered item or service, private transportation (A9270) provided October 4, 2022, to October 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the enrollee clinically qualifies for 
and medically meets criteria for a group 3 power wheelchair with power tilt. The Plan denied your request. The 
Plan says that although there are two approved power options on this wheelchair (tilt and elevating leg rests), 
there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is functionally non-ambulatory and requires a power wheelchair for 
mobility and performing her basic daily activities. They cannot independently perform transfers, are at risk for 
falling, and therefore requires power tilt. The enrollee also requires power tilt for adequate pressure relief. Our 
reviewer found that the enrollee requires power elevating leg rests for positioning of their lower extremities. 
The complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. Our physician reviewer also found that the electronic connection is necessary to operate the 
group 3 power wheelchair base and the power options via a joystick. It is required to operate the power options 
on a group 3 power wheelchair. 
 
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 electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet requirements for an LTACH admission. 
 
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 is receiving appropriate care in a current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
 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 LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo solution.  
You asked the Plan to pre-approve Vabysmo solution. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Vabysmo solution. Our reviewer says 
that the documentation does not support that the requested drug meets step therapy criteria. Our physician 
reviewer found the enrollee has age related wet macular degeneration. The documentation does not support that 
the enrollee has tried and failed Byooviz. The documentation does not support that Byooviz would likely be 
less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo solution have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vabysmo solution.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. There is no compelling rationale presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception.  
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 (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of an incompetent vein 
(36482) and sclerotherapy of the 2mm and 3mm varicosities (36471). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services.  
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter, and if the patient remains symptomatic after a six-week trial of conservative 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 these services. Our reviewer says that 
the enrollee does not meet criteria for coverage of the requested services. Our physician reviewer found that the 
enrollee has a diagnosis of lower extremity venous insufficiency with varicose veins and complications. The 
provided records in this case do not document that the veins in question are greater than 4 mm in diameter as 
required for coverage by the Local Coverage Determination.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of an incompetent vein (36482) and sclerotherapy of the 
2mm and 3mm varicosities (36471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a syringe (A4657), an epoetin alfa injection (Q4081) and an 
iron sucrose injection (J1756) related to end-stage renal disease (ESRD) provided on April 22, 2023. 

You asked the Plan to pay for the ESRD-related services and supplies. You say that you disagree with the 
denial and request payment on this claim. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related services and supplies. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD services are not separately 
payable. The ESRD PPS implemented consolidated billing requirements for limited Part B items and services 
are included in the ESRD facility's bundled payment. No other payment for these services is allowed. 
Therefore, we decided that the Plan does not have to pay for a syringe (A4657), an epoetin alfa injection 
(Q4081) and an iron sucrose injection (J1756) related to end-stage renal disease (ESRD) provided on April 22, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve S1 vertebroplasty (22511). 
 
You asked the Plan to pre-approve S1 vertebroplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records show the enrollee does not have osteoporosis, or that the enrollee has 
failed conservative management. 
 
The Plan follows Medicare rules. Medicare rules say that vertebroplasty can be covered when specific critera 
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 S1 vertebroplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not clearly evident regarding an acute or subacute compression fracture at S1. Additionally, there is no 
documentation of a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration 
of other plausible causes of 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 S1 vertebroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve S1 vertebroplasty (22511).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01402 and 64447 rendered on March 7, 
2023. 
 
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 the denied codes remain 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. 
 
We find that CPT codes 01402 and 64447 are not supported in the medical record. Specifically, the records do 
not contain the enrollee's name. It cannot be verified if the services were rendered to this enrollee. 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 procedure codes 01402 and 64447 rendered on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for procedure code 87506. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this code is not supported in the medical records 
provided. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 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 87506. Our reviewer says that this code is 
not supported. Our reviewer found the laboratory report does not support 6-11 targets. There is a more specific 
code to report for the number of targets tested. Therefore, this procedure cannot be verified. 
 
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 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 billed for date of service February 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from July 12, 2022, to August 19, 
2022. 
 
You asked the Plan to pay for home health care. You say that this change should be reconsidered. The Plan 
denied your request. The Plan says medical records support changing to code 1HB11. 
 The Plan follows Medicare rules. Medicare rules state that the payment rate for home health claims is based on 
the coding of the claim. 
 
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 home health care. Our reviewer says that this 
claim does not meet criteria for payment. Our physician reviewer found home health billing code 2HB11 was 
used. 2HB11 is a code for an episode of home care following discharge from an inpatient facility in the 
previous 14 days. An observation stay is an outpatient stay and is not an acute facility admission or admission 
to any facility. The Plan has re-coded the claim properly as the enrollee did not begin an episode of care within 
14 days of a prior inpatient facility stay. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pay for home health care provided from July 12, 2022, to August 19, 2022.