Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0561) and sleeves 
(E0667) for the enrollee. 
 
You asked the Plan to pay for these services. You say that these items were medically necessary for the 
enrollee The Plan denied your request. The Plan says that this was a non-covered service. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 these services. Our reviewer says that the 
pneumatic compression device and sleeves were not medically reasonable and necessary for the enrollee. The 
documentation does not reveal objective evidence of one or more venous stasis ulcer(s) on a physical 
examination. The patient was noted to have 2+ edema on a physical exam. There is no evidence of details of a 
failed six-month trial of conservative therapy directed by the treating practitioner. It is not clear exactly what 
conservative modalities the patient had and objective detailed measurements of the extremities with the trial or 
any objective progress notes of this trial. Without evidence of the aforementioned findings the pneumatic 
compression device and sleeves were not medically reasonable and necessary for the patient this case. Our 
physician reviewer found that the enrollee's condition did not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E0561) and sleeves (E0667) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this service is considered experimental and investigational. 
 
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 requested services are not considered medically reasonable and necessary in this case. 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. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of a CardioMEMS device. 
 
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 device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for a hip procedure. 
 
You asked the Plan to pre-approve inpatient services. You say that the enrollee is expected to require inpatient 
care based on history, comorbidities, current medical needs, and risk of an adverse event. The Plan denied your 
request. The Plan says the records do not indicate the presence or expectation for severe perioperative acute 
complications. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights.  
 
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 inpatient services. Our physician 
reviewer found that the documentation pre-operatively does not meet the threshold for an intensity of services, 
or underlying hemodynamic instability that could only be managed in an acute inpatient setting. The records do 
not show that the enrollee has a condition which would require inpatient care for the approved surgery. 
Therefore, the requested inpatient care is not medically reasonable or necessary for the enrollee's surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services for a hip procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal for a bicuspid tooth (D3320) provided on 
August 28, 2020. 
 
You asked the Plan to pay for the root canal. You say that you had the root canal on the same tooth. You say 
that you were told that the root canal fill was done correctly. The Plan denied your request. The Plan says root 
canal for a bicuspid tooth is listed with NC, or not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan 
does not have to pay for the root canal for a bicuspid tooth (D3320) provided on August 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required supervision/contact 
guard assistance for mobility. The enrollee required supervision for bathing and toilet transfers. The enrollee 
required supervision/minimal assistance for activities of daily living. The documentation does not support that 
the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation 
does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical 
matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on October 1, 2020. 
 
You asked the Plan to pay for the eyewear. You say that you believed this was covered. The Plan denied your 
request. The Plan says that you have exhausted this benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard lenses and frames limited to 1 pair of lenses and frames every 2 years.. 
 
We looked at the file and the Plan's rules. The file indicates the Plan covered eyewear for you on August 1, 
2019. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay separately for the physician services provided on July 6, 2020. 
 
You asked the Plan to pay separately for the physician services rendered during inpatient hospitalization. You 
say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid 
separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or 
hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers.  
 
This was an inpatient service. Payment for this service would have been included under the global facility 
claim. Payment to you for this service is the responsibility of the facility or hospital.  Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay separately for the physician services provided on July 
6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a drug implant device (11981) and an 
Etonogestrel implant system (J7307) provided on October 12, 2020. 
 
You asked the Plan to pay for the insertion of a drug implant device and the Etonogestrel implant system. You 
say that the medical records provided support the services in dispute. The Plan denied your request. The Plan 
says birth control devices and procedures are non-covered. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
The documentation does not show that this service is being requested to treat a specific illness/injury. As such, 
the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan 
does not have to pay for the insertion of a drug implant device (11981) and an Etonogestrel implant system 
(J7307) provided on October 12, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an x-ray provided  on September 
10, 2020, to September 14, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with these charges. The 
Plan denied your request. The Plan says that the correct copayments have been applied. 
 
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 has failed to send in information that would allow us to render a 
decision. Therefore, we decided that the Plan has to waive the copayment for an x-ray provided  on September 10, 2020, to September 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. 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 
was admitted for right hip and right radial fracture after a fall. Surgical repair of hip fracture was performed. 
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, and 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. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory tests (80307, G0482) provided on January 27, 2020. 
 
You asked the Plan to pay for laboratory tests. You say that these tests are supported in the records. The Plan 
denied your request. The Plan says there is no evidence of any relationship between the enrollee and the 
ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. The submitted medical records do not include any documentation 
showing that the ordering physician was treating the beneficiary. Based on this information, we decided that 
Medicare rules for coverage of laboratory tests have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory tests (80307, G0482) provided on January 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the decompression of spinal cord surgery (63056). 
 
You asked the Plan to pre-approve the decompression of spinal cord surgery. You say that this surgery is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this surgery does 
not meet medical necessity criteria. 
 
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 decompression of spinal cord 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the criteria for lumbar surgery is not met. There is no 
documentation of a recent trial and failure of physical therapy (PT) for back pain. There are no red flags for 
surgery present at this time. Therefore, the surgery is not 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 decompression of spinal cord surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the decompression of spinal cord surgery (63056).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts (foot orthotics) to be obtained 
from an out-of-network provider. 
 
You asked the Plan to pre-approve foot orthotics. You say that it would be a hardship for you to travel to the 
Plan's in-network provider. The Plan denied your request. The Plan says the denial of authorization for these 
items is correct, because this provider is out-of-network with the Plan and you can obtain foot orthotics from an 
in-network supplier. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve diabetic shoes and inserts (foot orthotics) to be obtained from an out-
of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have ongoing swelling and 
wearing a compression sleeve helps. The Plan denied your request. The Plan says that this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction (64635, 
64636). 
 
You asked the Plan to pre-approve paravertebral facet joint nerve destruction. You say that this is necessary to 
relieve the enrollee's pain. The Plan denied your request. The Plan says the documentation does not show that 
the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the destruction of cervical, thoracic or lumbar 
paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary if 
the paravertebral facet joint(s) have been identified as the source of the patient?s pain by undergoing a 
diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain 
suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment. 
 
We looked at the file and Medicare rules. Though the record shows that a median branch block was performed 
on the enrollee, the medical records do not document the results of this block. Based on this information, we 
decided that Medicare rules for coverage of paravertebral facet joint nerve destruction have not been met. 
Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction 
(64635, 64636).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the enrollee needs a full 
cardiac work-up, given her grossly abnormal EKG. You say that the enrollee would not be able to satisfactorily 
do a treadmill test because of her morbid obesity and struggle walking due to edema. The Plan denied your 
request. The Plan says the requested services are not medically necessary and do not meet Medicare criteria for 
coverage. 
 
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 myocardial perfusion imaging. Our 
reviewer says that myocardial perfusion imaging is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has some coronary risk but no symptoms suggestive of 
coronary ischemia, a normal cardiac physical exam and no ischemic ECG changes.  In this circumstance the 
documentation does not support the medical necessity for nuclear stress testing.  Screening stress testing, even 
in high risk patients, has not been shown to improve cardiac outcome. 
 
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 myocardial perfusion imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 13, 
2020. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith. You say that the services were medically necessary and meet all of the applicable professionally 
recognized standards of healthcare. The Plan denied your request. The Plan says the enrollee's claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's 
responsibility to verify the member's coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 13, 
2020.