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

 
We decided that the Plan does not have to pre-approve surgery to place an interspinous process stabilization 
device. 
 
You asked the Plan to pre-approve surgery to place an interspinous process stabilization device. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says [Enter plan 
denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 surgery to place an interspinous process 
stabilization device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral low back pain 
and bilateral leg and foot pain. The requested device is considered experimental. More research is needed to 
show safety and efficacy. Therefore, the enrollee does not meet 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 surgery to place an interspinous process stabilization device have not been met.  
Therefore, we decided that the Plan does not have to pre-approve surgery to place an interspinous process 
stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel provided on July 8, 2019. 
 
You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says the lab is not a 
Medicare benefit for the diagnosis listed on the claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive metabolic 
panel provided on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on April 
13, 2020. 
 
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the 
orthoses were medically necessary. The Plan denied your request. The Plan says the submitted documentation 
did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. 
 
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 knee orthoses (L1851) and suspension 
sleeves (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer 
found the enrollee was diagnosed with unilateral primary osteoarthritis of the left knee. A request for knee 
orthoses (L1851) and suspension sleeves (L2397) was made following a telehealth visit. The enrollee reported 
chronic instability of the left and right knees related to rheumatoid arthritis and osteoarthritis. The enrollee has 
not been to a physical therapist. The enrollee tested positive for pivot shift test on both knees. No other direct 
physical findings were noted. Upon review of the notes, there was no mention of prior used braces or devices 
for arthritis, clarity regarding the diagnosis of both rheumatoid and osteo arthritis and how the rheumatoid 
arthritis was being addressed by other doctors. No clinical information was noted suggesting evidence to rule 
out infection or other diagnoses of the knees to justify bypassing a work-up. Also, there was no report of the 
symptoms being acutely worse now, getting worse, or better. The enrollee has not yet tried physical therapy 
and had no recent history of a significant injury or surgery. Based on the limited supportive information, it 
appears the criteria for the knee orthoses (L1851) and suspension sleeves (L2397) is 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 knee orthoses (L1851) and suspension sleeves (L2397) have not been met. 
Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided 
on April 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office services, an EKG and 
echocardiography, provided from March 16, 2020 through March 17, 2020 by an in-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that your tests were classified as 
diagnostic and not screening services. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
 
Review of the file shows that you received specialist office services, an EKG and echocardiography, from 
March 16, 2020 through March 17, 2020 by an in-network provider. You are asked to pay a $35 copayment for 
services obtained from an in-network specialist. The Medicare-allowed amount for the EKG is less than the set 
$20 copayment; therefore, you have been asked to pay the lesser amount of $16.35 for the EKG and a $110 
copayment for echocardiography. Your EOC states that enrollees must pay a $20 copayment for Medicare-
covered non-radiological diagnostic services, a $110 copayment for each Medicare-covered radiological 
diagnostic service, not including X-rays, performed in a physician?s office or at a freestanding facility (such as 
a radiology center or medical clinic), and a $35 copayment for services obtained from a specialist, or under 
certain circumstances, treatment by a nurse practitioner or physician?s assistant or other non-physician health 
care professionals in a specialist?s office (as permitted under Medicare rules). 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 specialist office services, an EKG and echocardiography, provided from March 16, 
2020 through March 17, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee 
on March 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not appended. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted indicates CPT 49560 - Repair initial incisional or ventral hernia; reducible was 
provided to the enrollee on March 12, 2020 by the same provider group and within the same specialty. Therefore the postoperative visit 99291 would require an appropriate modifier when billed to the health plan because CPT 49560 has a 90 day global period. Although the medical records do validate the Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes was unrelated to the procedure performed on March 12, 2020, it is not eligible for reimbursement because an appropriate modifier was not appended when 99291 was billed. 
 
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 pay for critical care services (CPT 99291) provided to the enrollee on March 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc knee injections. 
 
You asked the Plan to pre-approve the Synvisc injections. You say that you believe that this is necessary for the 
enrollee. The Plan denied your request. The Plan says there was not sufficient positive response to the prior 
injection to support repeat treatment. 
 
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 Synvisc injections. Our reviewer 
says that the requested use of Synvisc is not shown to be medically reasonable and necessary. Our physician 
reviewer found the documentation does not include imaging studies showing severe degeneration joint disease 
of the knee. 
 
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 Synvisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc knee injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you were previously hospitalized and 
treated for a respiratory infection which left you in a diminished state. You say that on the date of service, you 
passed out in your bathroom and you were carried to your bed. Your son called 911 and when the ambulance 
responders arrived, they checked your vitals. You stated that their evaluation of your vitals showed that your 
condition did not warrant a trip to the emergency room as you were already recovering. You say that the 
emergency responders determined that a trip to the hospital was not necessary and so the ambulance did not 
transport you. You asked the Plan to reconsider their decision and provide coverage for the ambulance services. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
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 ongoing skilled services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity weakness. You 
were found to have severe lumbar canal stenosis. You had lumbar decompression surgery. All medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you do need physical and occupational therapy, the 
rehabilitation needs are not complex and do not require an intensive rehabilitation 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 IRF. 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 pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
hypertension, hyperlipidemia, esophageal reflux, deep venous thrombosis, COPD and NYSHA Class III 
congestive heart failure with preserved left ventricular ejection fraction (LVEF 50-55%) requiring 
hospitalization. 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. 
The CardioMEMs is considered experimental/investigational in nature and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computed tomography 
(SPECT) test. 
 
You asked the Plan to pre-approve SPECT test. You say that you are having chest pains but had trouble doing a 
stress test. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this test is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that cardiovascular nuclear testing such as SPECT tests are 
only covered for the clinical indications 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 SPECT test. Our reviewer says that you 
do not meet the Medicare criteria for the requested SPECT test. Our physician reviewer found you report 
episodes of chest pain and shortness of breath. Your treating physician noted an examination within normal 
limits and electrocardiogram without significant findings. You do not meet any of the clinical indications for 
the requested SPECT test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computed tomography (SPECT) test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care could be provided in the current inpatient hospital. 
 
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 is currently undergoing treatment at an ACH for pneumonia, dysphagia 
and aspiration. The enrollee received a tracheotomy and is noted to be tolerating a daytime tracheotomy collar. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's needs are being met in current setting. 
 
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. The patient 
is currently undergoing treatment at an acuted care hospital (ACH) for CoViD-19. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH 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 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: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been 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 enrollee's needs are being met in the current acute hospital setting. The LTACH 
cannot provide any services the current facility is not already providing. The enrollee can remain in the current 
hospital setting until such a time that they are ready for discharge to a lower level of 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 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 enrollee meets criteria for LTACH 
admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is 
correct. 
 
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 as LTACHs and acute care hospitals are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute 
care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of 
care for any ongoing long-term care needs. 
 
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.