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

 
We decided that the Plan has to pay for rotary wing air transport ambulance service and rotary wing air mileage 
provided on November 7, 2022. 
 
You asked the Plan to pay for the rotary wing air transport ambulance transport and rotary wing air mileage. 
You say that the patient was suffering from a life-threatening emergency medical condition. The Plan denied 
your request. The Plan says that the entire clinical situation, information provided at the time of the appeal does 
not support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the rotary wing air transport ambulance 
transport and rotary wing air mileage. Our reviewer says that the rotary wing air transport and mileage was 
medically necessary. Our physician reviewer found the enrollee reportedly had six separate episodes of 
ventricular tachycardia that morning, each coupled with shocks from her internal pacemaker/defibrillator. The 
enrollee was receiving a lidocaine infusion. The patient care record documents that ca ritical care unit was 
unavailable at the sending hospital.  
 
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 rotary wing air transport ambulance transport and rotary wing air mileage 
have been met. Therefore, we decided that the Plan has to pay for rotary wing air transport ambulance service 
and rotary wing air mileage provided on November 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance, including arthrography (27096). 
 
You asked the Plan to pre-approve bilateral prolotherapy injections. You say that the requested injections are 
medically necessary. The Plan denied your request. The Plan says this injection 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bilateral prolotherapy injections have not been met. Specifically, the NCD states, the medical 
effectiveness of the requested therapy has not been verified by scientifically controlled studies. The requested 
injections are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-
approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance, including 
arthrography (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve a partial denture. You say that the requested denture is medically necessary. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 1, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (A0425, A0428, A0382) 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergency transportation. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says this service is available 
in-network. 
 
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 
non-emergency transportation (A0425, A0428, A0382) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  multiple venous procedures intravascular ultrasound 
(tiny camera inside your veins to see and operate) followed by angioplasty (vein dilation) and stenting 
(placement of a tube to keep vessel open) with sedation (75822, 75820, 75825, 36011, 36012, 37252, 37253, 
76937, 99152 and 99153). 
 
You asked the Plan to pre-approve the services. You say that this procedure is to improve the enrollee's 
circulation and rule out May-Turners syndrome. The Plan denied your request. The Plan says the enrollee's 
records do not show they have acute symptoms such as blood clots. The Plan states the enrollee has not had 
initial testing such as computed tomographic (CT) or magnetic resonance (MR) venography.  
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support the medical necessity of venography and potential iliac 
venous intervention. There is no evidence of whole leg swelling and no documentation suggesting proximal 
venous disease on noninvasive imaging. In the absence of an indication for treatment or findings suggestive of 
significant iliac venous disease, our physician reviewer was unable to overturn the Health Plans 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  multiple venous procedures intravascular ultrasound (tiny camera inside your veins to see 
and operate) followed by angioplasty (vein dilation) and stenting (placement of a tube to keep vessel open) 
with sedation (75822, 75820, 75825, 36011, 36012, 37252, 37253, 76937, 99152 and 99153).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the SNF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria and is reasonably 
expected to participate and benefit from 15 hours of therapy per week and required daily physician oversight to 
actively manage medical conditions and comorbidities. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met.  
 
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 that the complexity of the enrollee's nursing, rehabilitation, and medical needs does 
not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. While the enrollee may have a need for physical therapy, and/or occupational therapy, the enrollee's 
rehabilitation needs can be provided in a lower intensity and alternate setting such as in an skilled nursing 
facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch glucose test strips. 
 
You asked the Plan to pre-approve One Touch glucose test strips. You say that you do not agree with the denial 
for the requested test strips. The Plan denied your request. The Plan says only the preferred brand products 
listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for One Touch glucose test strips. Therefore, we decided that the Plan does not have to pre-approve One Touch 
glucose test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 20, 2022, billed 
with codes 88377 and G0452. 
 You asked the Plan to pay for the testing as billed. You say that these codes should also be paid as a modifier 
was used.  The Plan denied your request. The Plan says the modifier is not supported as clinically appropriate.  
 
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 codes 88377 and G0452 are column II codes in relation to column I codes 
81219, 81270, 81279, and 81338; however, 88377 and G0452 were billed with a modifier.  
 
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 testing as billed. Our reviewer says that the codes at issue 
are not supported as payable with the Column I codes. Our reviewer found the record includes a laboratory 
report, that does not include documentation to support code 88377 is an unusual non-over lapping procedure 
from the paid services 81219; 81270; 81279 and 81338 which have an NCCI edit. This procedure cannot be 
verified, as documentation does not support the service and modifier billed.  
 
A molecular pathology procedure, physician interpretation, and report were found in the 
documentation. Procedures reported and reimbursed include interpretation and report. In this case, this 
procedure and modifier cannot be verified, as it would be included in the paid procedure codes. 
 
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 testing as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the laboratory testing provided on October 20, 2022, billed with codes 88377 and G0452.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on January 10, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee is not having documented hypoglycemia 
during their blood glucose checks at home, but they are having hypoglycemic symptoms. You also say that 
monitoring the enrollee with a CGM, even for a short time, would help you understand if it is hypoglycemia or 
if it is from something else. The Plan denied your request. The Plan says this enrollee does not have 
documentation of history of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found a CGM can often be inaccurate 
at lower blood glucoses (BGs) in the 50 to 70 range. Our reviewer also found that using a CGM to detect low 
BGs in this enrollee may indeed cause more confusion than not using it at all since they may think their BG is 
low according the CGM, but indeed it is not low enough to actually be causing low BGs. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
October 28, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing 
needs can be provided at a lower level of care.  
 
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 that the documentation does not support the necessity for admission to an IRF due to 
the lack of acute medical illness/complexity or nursing needs and high functional level. The enrollee's 
rehabilitation needs can be provided in an alternate and low intensity setting such as in-home with continued 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac (SI) joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (27279). 
 
You asked the Plan to pre-approve the service. 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. 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative treatment 
directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine are evident. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested SI joint arthrodesis, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, sacroiliac (SI) joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of back pain is not clear. There is no magnetic resonance imaging (MRI) showing 
only modic changes without facet degenerative joint disease (DJD) or foraminal 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (64628 and 64629).