Persius/hicric huggingface dataset:
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 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 history of chronic kidney disease, hypertension, diabetes, coronary artery disease, 
atrial fibrillation, hyperlipidemia, pacemaker placement and NYHA Class III congestive heart failure with 
preserved LV ejection fraction (LVEF 60%) requiring hospital admission.  
 
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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 
You asked the Plan to pre-approve Genvisc. You say that the requested Genvisc is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Synvisc, Durolane, and Gelsyn-3 first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found this appeal considers the request 
for Genvisc for the treatment of osteoarthritis in the right knee. The enrollee has not trialed Synvisc, Durolane, 
and Gelsyn-3.  Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not 
outline contraindications or reasons these medications were not considered. Without the support of the 
documentation, Genvisc is not approved as step criteria 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (CPT Code J7325). 
 
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 Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Synvisc (CPT Code J7325).  
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on May 28, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you weren't able to perform the CT 
scan, so you had to leave the hospital. You say that you dispute the claim. The Plan denied your request. The 
Plan says the copayment applied 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 $90 
copayment for emergency services in an emergency room. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you received treatment in the ER. 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 ER visit provided on May 28, 2020.  
 
Your complaint about being unhappy with the services you received and the way you were treated is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services received June 22, 2020 to July 24, 
2020. 
 
You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the home health services received June 
22, 2020 to July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and the filling (D2330) provided on July 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out of 
network. You say that you have been going to him for several years. You also say that you should not be held 
responsible for the bill because of this. The Plan denied your request. The Plan says there is no coverage for 
when services are rendered by an out of network provider. The Plan also says that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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, there is no coverage for when services 
are rendered by an out of network provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), prophylaxis (D1110), and the filling (D2330) provided on July 21, 2020.
Appeal type: Lab
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 May 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto Tab.
You asked the Plan to pre-approve Xarelto Tab. You say that you want the enrollee treated with this drug. The
Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
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 Xarelto Tab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services rendered on June 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code J3490 is 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. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, the documentation does not 
support the billing of one further unit of this code. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug services rendered on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were never notified that prior approval is 
necessary for cytology testing. The Plan denied your request. The Plan says the enrollee's plan requires 
utilization of network providers, and authorization for certain services. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the lab 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 lab services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagus biopsy provided on 
September 16, 2020. 
 
You asked the Plan to waive the copayment for the esophagus biopsy. You say that the biopsy was done for a 
pre-existing condition. The Plan denied your request. The Plan says the copayment applied 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 $125 
copayment for each Medicare-covered ambulatory surgical center visit. 
 
You have been asked to pay a $125 copayment for the esophagus biopsy. The esophagus biopsy falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. The esophagus biopsy is considered a surgical procedure. 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 esophagus biopsy provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (14041) provided May 13, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
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 14041 is  Adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet: defect 10.1 sq cm to 30.0 sq cm. 
 
We find that CPT code 14041 is not supported in the medical record. Specifically, the operative report does not 
include the documentation of a adjacent tissue transfer or rearrangement to confirm services were performed. 
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been 
met. Therefore, we decided that the Plan does not have to pay for surgical services (14041) provided May 13, 
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee has a history of cerebral vascular accident and is 
living in the home. He has worsening back pain and weakness despite home physical therapy services. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 
Services could be provided in an alternate level of care. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for electroencephalographic monitoring (95951) provided on October 23, 
2019. 
 
You asked the Plan to pay for the electroencephalographic monitoring. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation does not support the service billed. 
 
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 95951 is  monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel 
telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical 
localization), each 24 hours. 
 
We asked our coder 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 electroencephalographic monitoring. Our reviewer says 
that CPT code 95951 meet criteria for billing and reimbursement consideration. Our reviewer found the 
procedure report clearly documents a start date and time, end date and time:, and that combined 
electroencephalographic and video recording was performed. 
 
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 electroencephalographic monitoring have been met. Therefore, we decided 
that the Plan has to pay for electroencephalographic monitoring (95951) provided on October 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Wrist Disarticulation Prosthesis with a Myoelectric 
Hand. 
 
 
You asked the Plan to pre-approve the prosthesis. You say that you would like reconsideration because the 
member meets criteria for this prosthesis. The Plan denied your request. The Plan says there is no indication 
this member could not use a standard body-powered prosthesis to meet the functional needs of the individual in 
performing activities of daily living. 
 
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 prosthesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it has not been documented that a standard body powered prosthesis is inadequate 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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Wrist Disarticulation Prosthesis with a Myoelectric Hand.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for an additional $185 towards the dental services. We decided that the 
Plan does not have to pay for any amount over the $1,000 maximum benefit. 
 
You asked the Plan to pay for an additional $185 towards the dental services. You say that the services should 
be processed under your medical coverage. You say that it was suggested to remove any known risk for 
infection in order to make you an appropriate candidate for surgery. You say that you had all dental caries 
removed as a result. The Plan says that the services in this case are dental in nature. The Plan says that there is 
a $1,000 dental allowance. The Plan says that the $1,000 allowance has been exhausted in processing this 
claim. 
 
 
 
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. 
 
We decided that the Plan has to pay for an additional $185 towards the dental services.  
 
The record shows that the Plan has only paid $815 towards the $1,000 maximum dental benefit. Therefore, we 
decided that the Plan has to pay for an additional $185 towards the dental services. 
 
We also decided that the Plan does not have to pay for any amount over the $1,000 maximum benefit for 
the dental services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, there is a maximum allowance of 
$1,000 for non-Medicare dental services. The Evidence of Coverages states that you are responsible for any 
amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay for any 
amount over the $1,000 maximum benefit for the dental 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmic biometry (92136) test 
provided on August 25, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for each covered diagnostic procedure or test at a network doctor's office.  
 
You have been asked to pay $59.87 for the diagnostic test provided at the network doctor's office. This is the 
Plan allowed amount which is less than the applicable copayment. 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 ophthalmic biometry (92136) test provided on August 25, 2020.