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

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided January 
9, 2020. 
 
You asked the Plan to waive the copayment for the mammogram. You say that this was a follow up to a prior 
screening mammogram so the copayment should be waived. The Plan denied your request. The Plan says since 
this was a diagnostic mammogram and not a screening mammogram, the correct copayment was 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 $45 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $45 copayment for the mammogram. the mammogram falls within the 
Outpatient Diagnostic Tests 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 diagnostic 
mammogram provided January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is considered 
medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested 
LTACH care is not considered medically reasonable and necessary in this case. 
 
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 was admitted to the current acute care hospital with acute hypercapnic 
respiratory failure after a PVP urology procedure. He required mechanical ventilation, pressors, supplemental 
oxygen and diuresis. The enrollee was also diagnosed with atelectasis and bronchospasm which were treated. 
He was treated with antibiotics for bacteremia. He has since been extubated and pressors were discontinued, 
but he required tracheostomy and is requiring ongoing critical care services at this time. Physical therapy was 
initiated. Although he is improving, his oxygen needs vary and are unstable. 
 
Although the enrollee requires additional acute care services for now, the enrollee appears to be improving and 
is likely to require less than an additional 25 days in the hospital. The enrollee does not require services in the 
proposed LTACH that are not already available at the current facility. Physical therapy and oxygen support can 
be safely and effectively administered at the current facility. There are no services at the proposed LTACH that 
the enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be appropriate when 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 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is considered 
medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested 
LTACH care is not considered medically reasonable and necessary in this case. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include intravenous antibiotics, surveillance laboratory studies, 
extensive sacral wound care, colostomy and foley catheter care, and therapy services. The documentation does 
not support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 system. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 system. 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 system 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system 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 a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the enrollee is with a diagnosis of Stage C, NYHA III Chronic systolic (congestive) heart failure, as well 
as coronary artery disease, lung cancer, chronic kidney disease, obesity, and obstructive sleep apnea. A 
biventricular ICD is in place. The enrollee's EF is 20-25%. She was admitted to the hospital in January, 2020 
with acute decompensated heart failure. The enrollee presented for routine follow-up on 2/20/20. She was 
doing well at that time. She was noted to be compliant with all medications. The enrollee's physical exam was 
unremarkable. 
 
It is not clear that the CardioMEMS HF System is medically reasonable and necessary for the enrollee in this 
case. The enrollee has been stable on her current regimen. The efficacy of the CardioMEMS HF System is 
uncertain and is debated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care from 7/28/20 to 8/3/20 for treatment of cerebral infarction. The enrollee transferred from acute care to 
Inpatient Rehab from 8/3/20-8/20/20. He has cognitive deficits and dysphagia; needs one on one supervision 
for all meals as per speech therapy. The enrollee is hemodynamically stable, and non-toxic. The enrollee is 
requiring maximum assist for most/all care.  
 
The enrollee is now maximum assist for care. The enrollee has no complex wound care needs, or IV 
medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as 
opposed to a lesser level of care.  The enrollee's vital signs are stable and SNF is not medically 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 admission to a SNF 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from April 18, 2019 to May 3, 
2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the provider had been paid twice for 
room and board charges, once by the enrollee and once by the Plan. You also say that the enrollee did not 
receive notice that room and board would not be covered. The Plan denied your request. The Plan says that the 
enrollee was issued and signed the Notice of Medicare Non-Coverage (NOMNC) acknowledging that these 
services would end on April 17, 2019. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any medical records for this case. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case. 
Hence, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan 
has to pay for the skilled nursing services provided from April 18, 2019 to May 3, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of proximal humeral (surgical or anatomical 
neck) fracture; without manipulation (CPT Code 23600) provided to the enrollee on October 17, 2019. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the billed procedure, 23600, was denied because it was reported without a required anatomical 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. When 
a service is provided that can be further clarified by an anatomical modifier, the applicable modifier should be 
used. CPT Code 23600 is denied because it was reported without a required anatomical modifier. CPT code 
23600 is for ?Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without 
manipulation?. In this procedure, the provider performs a closed treatment of a surgical or anatomical neck 
fracture of the upper end of the humerus. The humerus is the long bone in an arm. Anatomic-specific modifiers 
such LT (Left side), RT (Right side), and 50 (Bilateral procedure) designate the area or part of the body on 
which a procedure is performed. These modifiers are required whenever they are appropriate. Therefore, we 
decided that the Plan does not have to pay for closed treatment of proximal humeral (surgical or anatomical 
neck) fracture; without manipulation (CPT Code 23600) provided to the enrollee on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the hyperbaric oxygen therapy treatments 
provided from February 28, 2020 to March 27, 2020. 
 
You asked the Plan to waive the copayments for the hyperbaric oxygen therapy treatments. You say that you 
were told your copayment would be $35 for 40 treatments and your insurance would pay the rest. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $35 
copayment for provider and professional services in an in-network specialist's office.  
 
You have been asked to pay a $35 copayment for each of the hyperbaric oxygen therapy treatments. ($35 x 3 
visits = $105). The hyperbaric oxygen therapy treatments fall 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 copayments for 
the hyperbaric oxygen therapy treatments provided from February 28, 2020 to March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 1, 2019 by a non-
network provider. 
 
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 services were rendered by a non-network provider without 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 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 medical services provided on October 1, 2019 
by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 15, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336 and 99490). You say that you would like 
reconsideration because it is the responsibility of the nursing home to obtain prior authorization for their 
patients. The Plan denied your request. The Plan says utilization of network providers is required when 
possible and available. 
 
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 medical services provided on October 15, 2019 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration because 
the nursing home is responsible to obtain prior authorization for their patients. The Plan denied your request. 
The Plan says utilization of network providers is required when possible and available. 
 
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 medical services provided on March 3, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services (90832) provided on 
March 14, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
There were network providers available. 
 
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 outpatient mental health services (90832) provided on March 14, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this is necessary due to the 
enrollee's calf pain. The Plan denied your request. The Plan says that the enrollee does not have symptoms to 
support the requested test. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the requested service is considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has a very high risk for cardiovascular disease based on her advanced age, 
hypertension, longstanding diabetes with evidence of end organ damage (neuropathy and retinopathy) and now 
complaints of exertional calf pain consistent with claudication due to large or small vessel peripheral arterial 
disease. Although she has no chest symptoms at present, she does not ambulate well and guidelines and 
published data support nuclear stress testing in these very high risk asymptomatic individual who have 
longstanding diabetes and symptoms of peripheral arterial disease. As she cannot exercise due to calf 
claudication she would require pharmacologic nuclear stress testing to assess for CAD. The test is therefore 
indicated and supported by published literature and guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the 
Plan has to pre-approve myocardial perfusion imaging (78452).  
 
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.