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

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are very weak and are at risk of falling. You say 
that this is the best option for the best care possible. The Plan denied your request. The Plan says your needs 
can be met 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 above. 
 
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 ongoing pain medication and other medication management, wound care, and 
daily therapy can be provided at a 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 8, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare does not cover cardiac genetic testing for screening purposes. 
 
Medicare rules say that providers must produce medical records showing why the genetic services provided 
were medically necessary. In this case, there were insufficient records provided to show the results of this 
testing would be used to determine a diagnosis or determine a treatment strategy for disease or illness present 
in the enrollee at the time of service. This testing is not covered for screening purposes. Medicare coverage 
criteria are not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the 
enrollee on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim NEO system. 
 
You asked the Plan to pre-approve Barostim NEO system. You say that this is medically necessary for you. 
The Plan denied your request. The Plan says that this is not covered under the current Medicare Category B 
Investigational Device Exemption Requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that providers participating in and seeking Medicare 
reimbursement for items and services in Category A or B IDE studies, prior to submitting claims, are 
responsible for checking the CMS Coverage Website to identify whether CMS (or its designated entity) has 
approved the study for purposes of Medicare coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Barostim NEO system have not been met. Specifically, the provider to render treatment in this 
case is not listed as an approved provider for this Category B IDE study. Therefore, we decided that the Plan 
does not have to pre-approve Barostim NEO system.
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. The Plan denied your request. The Plan says transfer 
to a LTACH is not medically necessary at this time. 
 
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 does not require services at the LTACH that are not available at the 
current setting. Our reviewer found that there are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
lower level of care may be considered at a later date. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel provided to the enrollee on December 
3, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the codes billed are part of a general health panel. The medical records provided give no 
specific diagnostic reason for these lab services. 
 
The Plan must follow Medicare rules. The rules say that providers must submit records to support the services 
billed are medically necessary. The records provided do not give a specific reason for these lab services other 
than being a general screening. Medicare billing criteria are not met. Therefore, we decided that the Plan does 
not have to pay for a general health panel provided to the enrollee on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, breast, without and with contrast material(s), 
including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic 
analysis), when performed; bilateral (CPT Code 77049). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has known history of breast cancer. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our physician reviewer found 
based on the documentation provided, the health plan's denial should be upheld. You have a history of breast 
cancer. At your January appointment, no interval signs, symptoms or imaging abnormalities were noted. As 
such, the requested MRI of the breast is not shown to be medically necessary or reasonable. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, breast, without and with contrast material(s), including computer-aided detection 
(CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral 
(CPT Code 77049).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, repair of paraesophageal hernia, 
includes fundoplasty, when performed; without implantation of mesh (CPT Code 43281). 
 
You asked the Plan to pre-approve the services. You say that it is medically indicated and in the patient?s best 
interest to separate the foregut procedures, including the removal of this complicated lap gastric band as well as 
repair of the hiatal hernia, from the hernia operations. You state to only repair the hernia would increase future 
risk of complications related to the gastric band as well as the need to traverse mesh in the future, if needed. 
The Plan denied your request. The Plan says the services are not 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 it is not medically necessary, and may not be in the patient's best interest, to separate the 
proposed foregut procedures. As noted in the Clinical Summary above Appellant has multiple comorbidities. 
The two stage repair proposed by the patient's provider, versus a one-stage approach, places the patient 
needlessly at twice the risks associated with anesthesia exposure, recurrent embolism, and prolonged post-
operative recovery. Further, the necessity of a repair of a "paraesophageal hernia" is not supported by the 
provided computed tomography (CT) imaging report that shows neither a para-esophageal hernia nor evidence 
of esophageal dilation. Indeed, the patient may benefit from motility and pH testing before any additional 
consideration is given to hiatal hernia repair. 
 
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 laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when 
performed; without implantation of mesh (CPT Code 43281).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee genicular nerve block. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure is considered 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 the requested services. Our physician 
reviewer found that the enrollee has low back pain and left knee pain. However, the physical exam progress 
note shows a normal knee exam. There is no recent imaging of her knee. Her last physical therapy was in 2014.  
The requested procedure is experimental/ investigational for osteoarthritis and is the subject of on-going 
clinical trials. Therefore, the requested procedure 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the positive airway device provided on 
January 10, 2020. 
 
You asked the Plan to waive the coinsurance for the positive airway device. You did not provide an argument 
for this cost sharing to be waived. The Plan denied your request. The Plan says you have been charged this 
coinsurance correctly under Plan rules.  The Plan states that you are eligible for Medicaid benefits.  The plan 
has reached out to the equipment vendor to advise them to submit the claim with your secondary Medicaid 
insurance.  The Plan also stated that it has sent your appeal documentation directly to your Medicaid insurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the positive airway device. The positive airway device falls 
within the durable medical equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the positive airway device provided on January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the procedure codes are 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 81225-90; 81226-90; 81227-90; 81230-90; 81231-90; 81240-90; 81241-90; 81328-90; 
81335-90; 81355-90; 81232-90; 81283-90; and 81408-90 are not supported in the medical record. Specifically, 
there are no submitted laboratory results for the billed date of service. 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 pay for the laboratory services rendered on February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0429) and ambulance mileage (A0425) provided on March 30, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment per trip for ground ambulance services provided.  
 
You have been asked to pay a $50 copayment for the ground ambulance service provided. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the ambulance transportation service (A0429) and ambulance 
mileage (A0425) provided on March 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services February 21, 2020 to March 21, 
2020 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 29, 
2019 to April 22, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services February 21, 2020 to March 21, 2020
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myotonic Syndrome Advanced Evaluation Test. 
 
You asked the Plan to pre-approve Myotonic Syndrome Advanced Evaluation Test. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 
 
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 Myotonic Syndrome Advanced 
Evaluation Test. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee was evaluated by neurology via 
telemedicine on July 28, 2020 regarding a myotonic disorder. The documentation does not support that 
Myotonic Syndrome Advanced Evaluation genetic testing will impact the treatment or the management of the 
enrollee's condition, based on published peer reviewed medical literature. CAV3, CLCN1, and DMPK are Tier 
2 non-covered codes per LCD L35000. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myotonic Syndrome Advanced Evaluation Test have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Myotonic Syndrome Advanced Evaluation Test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met. 
 
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 patient in this case appears to be still recovering and requires additional physical 
therapy and dietary monitoring. There was no indication the enrollee would likely require more than 24 days of 
acute care services. The enrollee does not require services at the LTACH that are not already available at the 
current facility. The enrollee can continue current treatment at the current facility.  Medicare coverage criteria 
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 the LTACH services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an interspinous process stabilization 
device. 
 
You asked the Plan to pre-approve the interspinous device. You say that the enrollee would benefit from this 
treatment. The Plan denied your request. The Plan says there are not sufficient current studies to support that 
this procedure is reasonable and 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 interspinous device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is currently experimental. More research is needed to show 
safety and efficacy. It is not needed in this case. There is no instability noted on examination. 
 
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 interspinous device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an interspinous process stabilization device.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 above. 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 in this case, the medical records show 
that you need almost maximum assistance for functional transfers and activities of daily living. It is not clear 
that you would be able to fully benefit and/or participate in an IRF level of care. Medicare coverage criteria 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 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.