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

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show enrollment in an approved Category B investigational device 
exemption study. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure.  Medicare 
coverage criteria are not met since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS HF device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on July 10, 2020, to September 22, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree that 
you should be charged for this. The Plan denied your request. The Plan says the correct coinsurance has been 
applied. 
 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $894.24. The total amount you are being asked to pay is $178.86 ($894.24 x 20% = 
$178.86). Durable medical equipment 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 durable medical equipment provided by a participating provider on 
July 10, 2020, to September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electroencephalography (EEG) test 
provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for EEG test. You say that once this test was completed you 
received improper treatment. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $30 
copayment for EEG test.  
 
You have been asked to pay $30 copayment for EEG test. EEG test falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 copayment 
for an electroencephalography (EEG) test provided on July 28, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided. 
 
You asked the Plan to pay for Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions 
(98943). You say that you were told the services were coded wrong. The Plan denied your request. The Plan 
says these procedures are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the lumbar-sacral 
orthosis, and the knee orthosis and suspension sleeve provided on July 20, 2020. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960), the lumbar-sacral orthosis 
(L0650), and the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says documentation did not include valid Proof of Delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, 
the lumbar-sacral orthosis, and the knee orthosis and suspension sleeve provided on July 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on March 9, 
2020. 
 
You asked the Plan to pay for the retroperitoneal ultrasound. You say that you would like reconsideration 
because this service was denied as a duplicate in error. The Plan denied your request. The Plan says the records 
reviewed do not support the service being performed more than once for the date of service by the rendering 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the retroperitoneal ultrasound have not been met. Specifically, the record indicates that CPT code 
76770 was previously approved and paid. The documentation submitted does not support that more than one 
unit of this service was rendered by the provider on the billed date of service. Therefore, we decided that the 
Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on March 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is unknown if you have failed to respond adequately to conservative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found there is no specific 
clinical rationale for the use of Synvisc. There is no documentation provided indicating the enrollee has failed 
to respond adequately to conservative non-pharmacologic therapy such as physical activity and exercise in the 
affected knees and simple analgesics (pain relievers) before using Synvisc-One. The review has determined 
that the documentation does not support that the injection is medically reasonable and necessary for the 
enrollee. At this time, the documentation does not support that the injection is safe and effective for the 
enrollee. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that the bitewing x-rays that you received were the 
only x-rays that you received this year. You say that you do not know why bitewing x-rays were provided 
instead of a covered x-ray. You say that you were not informed that you would have to pay for the x-rays. You 
also say that The Plan denied your request. The Plan says bitewing x-rays are not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-rays (D0274) provided on August 7, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve right knee arthroscopy with medial meniscectomy identified with 
code 29881. 
 
You asked the Plan to pre-approve right knee arthroscopy with medial meniscectomy. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services 
are not medically necessary. 
 
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 right knee arthroscopy with medial 
meniscectomy. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee presents with a history of chronic right knee 
pain. The enrollee is now reporting pain interferes with activities of daily living and his work ability. Clinical 
exam findings are consistent with imaging evidence of a complex right knee medial meniscus tear. There is 
radiographic evidence of mild early degenerative changes of the right knee. The enrollee had failed to improve 
with conservative treatment, including activity modification, medications, and physician-directed home 
exercise program. Current evidence based medical literature would support proceeding to surgery given the 
failure of conservative treatment, persistent symptoms, functional limitations, positive meniscal provocative 
testing, and imaging findings. Therefore, the enrollee meets criteria for the requested 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 right knee arthroscopy with medial meniscectomy have been met. Therefore, we 
decided that the Plan has to pre-approve right knee arthroscopy with medial meniscectomy identified with code 
29881.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 15004) provided on July 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 
cannot be verified. 
 
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 15004 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 
100 sq. cm or 1% of body area of infants and children." 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 15004 is not supported by the records provided. Our coding reviewer found that the operative 
report did not include documentation of "surgical preparation or creation of recipient site" was a separate 
procedure. CPT 15004 would be reported when healing the wound by primary intention. The documentation 
supports preparation of the wound by secondary intention. This would not be separately reported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 15004) provided on July 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of a shoulder dislocation (23670-22) 
provided on March 4, 2020. 
 
You asked the Plan to pay for the open treatment of a shoulder dislocation. You say that this is supported. The 
Plan denied your request. The Plan says this is not documented in the records. 
 
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 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 open treatment of a shoulder dislocation. 
Our reviewer says that the billing of this code with this modifier is not supported. Our physician reviewer 
found the operative report does not clearly support modifier 22 for increased procedural services. To report 
modifier 22, the documentation requires detailed evidence of the extra difficulty encountered in comparison to 
the work that would normally be expected for the procedure performed. 
 
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 open treatment of a shoulder dislocation have not been met. Therefore, we 
decided that the Plan does not have to pay for the open treatment of a shoulder dislocation (23670-22) provided 
on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral ablation procedure (64451). 
 
You asked the Plan to pre-approve the sacral ablation procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is considered investigational and 
is not covered. 
 
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 sacral ablation procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found Sacroiliac Joint Procedures (used to treat pain in the hip region), have not proven 
to be helpful. It is considered experimental or investigational. This includes sacral lateral nerve branch blocks 
or ablations. 
 
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 sacral ablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacral ablation procedure (64451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 21, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the facility should have 
requested authorization. The Plan denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 21, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 11, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $20 
copayment per visit to a specialist.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner services, including doctor?s office visits 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 copayment for a specialist visit provided on August 11, 2020.