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

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to 
show safety and efficacy. Iliac crest bone graft remains the gold standard. 
 
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 bone marrow aspiration.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker (CPT Code 33274). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the records do not indicate that the enrollee is enrolled in a clinical trial. The Plan states 
a call was placed to the provider?s office to inquire if the enrollee is enrolled in a clinical trial and the office 
confirmed that the enrollee is not enrolled in a trial at this time. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The enrollee is not enrolled in a 
clinical trial. The rules say that leadless pacemakers are non-covered when furnished outside of a CMS 
approved CED study. Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion 
or replacement of permanent leadless pacemaker (CPT Code 33274).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425RP, A0428RP) provided on 
September 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed and 
approved for payment due to medical necessity of ambulance transport. The Plan denied your request. The Plan 
says a physician's office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services (A0425RP, A0428RP) 
provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve leadless pacemaker (33274). 
 
You asked the Plan to pre-approve leadless pacemaker. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the medical information received does not show member is part of a 
Medicare approved clinical trial or prospective longitudinal study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve leadless pacemaker (33274). Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found leadless pacemakers are currently considered under investigation and there is no 
indication this patient is associated with an ongoing FDA approved study or a prospective longitudinal follow 
up study.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of leadless pacemaker have not been met. Specifically, the item requested is 
considered investigational and there is no evidence that the enrollee is in a clinical trial or longitudinal study. 
This means the services is not medically necessary or reasonable. Therefore, we decided that the Plan does not 
have to pre-approve leadless pacemaker (33274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on September 22, 
2020. 
 
You asked the Plan to waive the copayment for vision care. You say that you were not aware that you would 
owe a copayment and would not have received the services if you had known. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct 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 exams to diagnose and treat diseases and conditions of the eye for vision care.  
 
The medical records show that you received vision care to diagnose or treat diseases and conditions of the eyes 
on September 22, 2020. Therefore, you are responsible to pay the $35 copayment.  
 
You have been asked to pay a $35 copayment for vision care. Vision care falls within the vision care 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 vision care provided on September 22, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for photopheresis provided on August 1, 2020. 
 
You asked the Plan to pay for photopheresis. You say that this treatment was medically necessary, and the 
enrollee has been receiving this treatment for more than two years. The Plan denied your request. The Plan says 
that plasmapheresis/photopheresis/apheresis is not covered by Medicare for the diagnoses on the claim. 
 
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 pay for photopheresis. Our reviewer says that the 
services is considered medically reasonable and necessary in this case. Our physician reviewer found 
Bronchiolitis obliterans (BO), also known as obliterative bronchiolitis, refers to the clinical syndrome 
associated with small airways injury caused by a spectrum of inhalational, infectious, and drug exposures, and 
also following lung or hematopoietic cell transplantation. BO related to a paraneoplastic syndrome from 
Castleman's is a rare occurrence but treated similar as disease is often refractory to standard treatments. 
Extracorporeal photopheresis is a standard treatment best studied after lung transplantation or from graft versus 
host disease. This patient has failed standard treatment. The service is reasonable and 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 photopheresis have been met. Therefore, we decided that the Plan has to pay for 
photopheresis provided on August 1, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular junction testing (CPT 95937) provided to the 
enrollee on August 21, 2020. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of myasthenia gravis or Lambert Eaton myasthenic syndrome 
(LEMS) or botulinum toxicity. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have a covered indication for neuromuscular junction testing as established by LCD 
L34996. The medical records in the case file are limited to an Oversight Physician Report with a date of service 
of 8/21/2020. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for neuromuscular junction testing (CPT 95937) provided to the enrollee on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration (CPT Code 20939). 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed 
to show safety and efficacy. Iliac crest bone graft is the gold standard for bone grafting in spinal fusion. 
 
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 a bone marrow aspiration (CPT Code 20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) 
provided on September 12, 2020. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the record provided does not support the billed items 
in this case. 
 
The Plan follows Medicare rules. Medicare rules say that records from suppliers or healthcare professionals 
with a financial interest in the claim outcome are not considered sufficient by themselves for determining that 
an item is 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 pay for this items. Our reviewer says that the record 
does not support the medical necessity of the billed items. Our physician reviewer found that the enrollee's 
chief complaint was chronic pain located in the left and right knee. The documentation in the case file does not 
support that the knee orthosis and suspension sleeve provided were medically reasonable and necessary for the 
enrollee. There is insufficient documentation of an examination of the enrollee, and there is insufficient 
credible objective documentation of joint laxity.  
Additionally, the suspension sleeve is not separately payable when the base item is not covered. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on major vessels of neck (CPT 
Code 00350 QX x 228 units) provided on May 18, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00350 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of Anesthesia for procedures on major vessels of neck; not otherwise specified; 
therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the 
provider for additional information. Document systems were searched, and it was determined that despite the 
appellant's assertions, no medical records were submitted with the appeal request. 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 anesthesia for procedures on major vessels of neck (CPT Code 00350 QX x 228 
units) provided on May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular radiofrequency ablation 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 this is considered experimental and unproven. 
 
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 this is considered an experimental/ investigational procedure that is currently the subject of on-going 
clinical trials. Therefore, the procedure is considered not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left knee genicular radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Novolog 100 unit/ml flexpen. 
 
You asked the Plan to pre-approve the Novolog 100 unit/ml flexpen.. You say that you would like 
reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this is 
not a covered benefit under Medicare Part B. 
 
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 the Novolog 100 unit/ml 
flexpen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the documentation shows that the enrollee has not trialed viscosupplemental treatments 
Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires both of these be trialed first. The 
documentation does not outline contraindications both of these medications were not considered. Without the 
support of the documentation, Gelsyn-3 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five further physical therapy (PT) visits. 
 
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 11 visits are covered and five further are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition. The records show that she is improving with therapy. It appears 
reasonable based on the records to re-evaluate her progress after completion of the approved eleven treatments 
to evaluate the need for further therapy. The records do not support that she requires the the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist or under the supervision of a therapist. The services are not 
required to maintain her current condition or prevent or slow deterioration. Five further PT sessions are 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 five further physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 22, 
2020, through July 21, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the continuation of skilled services can be provided on an intermittent basis on an 
outpatient basis, in a long-term care facility, or in the home with home health care service. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found this beneficiary does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  
 
 
 
 
 
There are no identifiable skilled nursing service needs and the beneficiary does not require skilled nursing or 
therapy services on a daily basis. 
 
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 care have not been met. Specifically, the enrollee does not meet the criteria 
for SNF care and the services can be obtained at a lower level of care. This means SNF care is not reasonable 
or necessary. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided on May 22, 2020, through July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
October 7, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you feel that the 
mammogram should be considered preventative, not diagnostic. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 $40 
copayment for each basic imaging service. 
 
The medical records show that you received a diagnostic mammogram on October 7, 2020, due to you history 
of breast cancer. Therefore, you are responsible to pay the $40 copayment.   
 
You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic mammogram provided on October 7, 2020.