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

We decided that the Plan does not have to pre-approve use of the CardioMEMS heart failure monitor. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the enrollee would benefit from 
the use of this monitor. The Plan denied your request. The Plan says there is still insufficient evidence to show 
this 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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has 
been demonstrated in only one 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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of the CardioMEMS heart failure monitor.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing services. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing services. You say that the clinical 
findings support the necessity of the periodontal scaling and root planing services in dispute, in order to 
properly address the enrollee's periodontal disease. You say that the enrollee's home care is substandard and 
irregular due to his Parkinson's disease. The Plan denied your request. The Plan says that deep gum and root 
cleaning for the lower left and lower right quadrant is not medically necessary at this time. 
 
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. The Plan covers the 
periodontal scaling and root planing services 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 the periodontal scaling and root planing 
services. Our reviewer says that periodontal scaling and root planing services are medically reasonable and 
necessary to treat the enrollee's periodontal disease. Our physician reviewer found a review of the enrollee's 
dental record and radiographs indicate that pathologic periodontal pocketing (4-5mm) along with areas of 
horizontal bone loss is present in the mandibular left and right quadrants. 
 
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 the periodontal scaling and root planing services have been met. Therefore, we 
decided that the Plan has to pre-approve periodontal scaling and root planing services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS HF system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. 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 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 the system. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has Class III CHF with heart failure with preserved ejection fraction. She is on a complex 
medical regimen and optimization of filling pressures and fluid status will be critical to keeping her out of the 
hospital with recurrent exacerbations. Cardiomems has been shown in randomized clinical trials and post 
marketing followup studies (1) to decrease recurrent hospitalization in these patient groups, especially those 
who have been hospitalized for CHF in the past 6 months. It is FDA approved for this indication as well. 
Cardiomems is therefore medically necessary and reasonable for monitoring of fluid status in this complex 
heart failure patient and meets Medicare criteria for use in this clinical situation. It is not considered 
investigational for this clinical purpose. 
 
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 system have been met. Therefore, we decided that the Plan has to pre-
approve the CardioMEMS HF system for the enrollee.  
 
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Viberzi Tab 100mg. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viberzi Tab 100mg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with 
respiratory failure due to pneumonia. The documentation shows that you have been worsening with chest x-
rays showing worsening pneumonia, requiring more intensive care. While the documentation does support that 
you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment, you can receive these services 
in the current setting until you are more stable for discharge. As a practical matter, you do not require the 
necessary services on an inpatient basis, at a SNF level of care. Your required services can be safely received in 
the current setting until you are more stable. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biomarker testing of cerebrospinal fluid (CSF) for 
evaluation of Alzheimer's disease (AD). 
 
You asked the Plan to pre-approve the CSF biomarker testing. You say that a diagnosis of Alzheimer's disease 
is uncertain in this enrollee's case and this testing would be beneficial for choosing targeted therapies. The Plan 
denied your request. The Plan says the current medical literature does not indicate that this testing benefits 
patients. 
 
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 CSF biomarker testing. Our 
reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this testing is not commonly and customarily performed in the evaluation of 
suspected AD. Rather, the diagnosis of AD is more commonly and customarily made on the basis of clinical 
examination (using standardized diagnostic criteria). Such an evaluation (based on diagnostic criteria) has a 
higher sensitivity than the proposed course of testing. In this regard the proposed service would not be expected 
to be as beneficial as an existing and available medically appropriate alternative. Nor would the proposed 
testing be necessarily furnished in accordance with generally accepted standard of practice/care. For these 
reasons, medical necessity has not been established. 
 
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 CSF biomarker testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve biomarker testing of cerebrospinal fluid (CSF) for evaluation of Alzheimer's 
disease (AD).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for intravenous infusion, hydration; initial, 31 minutes to 1 hour (96360) 
provided April 6, 2020. 
 
You asked the Plan to pay for code 96360. You say that this service was medically necessary. The Plan denied 
your request. The Plan says that this was incidental hydration. 
 
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 Coder 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 code 96360. Our reviewers says that the 
billing of code 96360 is supported in this case. Our Coder reviewer found the patient received via IV, Sodium 
Chloride (NS) 0.9% bolus 1,000 mL - Dose; 1,000 mL; Rate; 2,000 mL/hr; Route: Intravenous; Line: 
Peripheral IV.  During the course of the time patient spent in the emergency room, documentation did not 
include medication other than normal saline administered via IV. 
 
We looked at this Coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 96360 have been met. Therefore, we decided that the Plan has to pay for 
intravenous infusion, hydration; initial, 31 minutes to 1 hour (96360) provided April 6, 2020.  
 
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 transcatheter placement of an intravascular stent(s) (37236) 
and selective catheter placement (36246) provided March 23, 2020. 
 
You asked the Plan to pay for codes 37236 and 36246. You say that the billed services were medically 
necessary. The Plan denied your request. The Plan says the billed 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 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 codes 37236 and 36246. Our reviewer says 
that codes 37236 and 36246 are not supported for payment. Our physician reviewer found the operative report 
documents intravascular stent placement across the popliteal artery. There is a more appropriate code than 
37236 to report for this procedure. Code 36246 would not be covered, if the primary code is denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 37236 and 36246 have not been met. Therefore, we decided that the Plan 
does not have to pay for transcatheter placement of an intravascular stent(s) (37236) and selective catheter 
placement (36246) provided March 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This 
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this provider is not in-network with the Plan. 
 
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 
the medical services 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 bone marrow aspirate as part of a spinal fusion 
procedure. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the services requested should be 
approved due to medical necessity. The Plan denied your request. The Plan says it was found that the surgery 
itself is medically appropriate, but the use of bone marrow aspirate is not proven and remains denied. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate as part of a spinal fusion procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion procedure. You say that the enrollee would benefit from this 
device. The Plan denied your request. The Plan says this procedure has not been shown to be 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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value of this device is not established. 
 
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 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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97116, 97112, 97110) 
provided on June 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services (97116, 97112, 
97110) provided on June 16, 2020, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you had 
on April 2, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you say that during the 
pandemic, the ER is sending everyone home and not allowing them to spend the night.  You said that normally 
you would have been admitted and the copayment would have been waived. The Plan denied your request. The 
Plan says you were charged this copayment correctly. 
 
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 $25 
copayment for emergency room services.  
 
You have been asked to pay a $25 copayment for the ER services. This copayment applies regardless of why 
you may not have been admitted. 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 emergency room (ER) 
services you had on April 2, 2020.