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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that your PCP advises that this be covered. The 
Plan denied your request. The Plan says you have used your maximum allowed one-way trips covered in your 
supplemental plan for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 based on the documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The 
enrollee's care needs can be met at 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve ferumoxytol injections (Q0138). 
 
You asked the Plan to pre-approve the ferumoxytol injections. You say that you would like reconsideration 
because these injections are medically necessary. The Plan denied your request. The Plan says that the 
documentation does not show that the member meets coverage criteria. 
 
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 ferumoxytol injections. Our 
reviewer says that this drug is medically reasonable and necessary. Our physician reviewer found the recent 
labs show that the member has chronic kidney disease, anemia and iron deficiency. 
 
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 ferumoxytol injections have been met. Therefore, we decided that the Plan 
has to pre-approve ferumoxytol injections (Q0138).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dorsal column neurostimulation trial for the enrollee. 
 
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the trial. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records provided for review did not include a record showing that the member had "undergone 
careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening 
must include psychological, as well as physical evaluation)". It was mentioned that the enrollee had received 
"psychological" clearance, but a copy of that evaluation/note was not provided within the records provided for 
review. This would ultimately not satisfy the requirements for coverage as outlined within the NCD for 
coverage of this service. 
 
 
 
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 trial have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a dorsal column neurostimulation trial for the enrollee.
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 the SNF admission. You say that the enrollee has COVID and requires daily 
skilled services in the isolation unit. The Plan denied your request. The Plan says the enrollee's needs are 
custodial. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs at this point are custodial and, as a practical matter, can be provided at 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Code C2624). 
 
You asked the Plan to pre-approve the device. You say that you are requesting review of denial of the device. 
The Plan denied your request. The Plan says the device is not 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has 
been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not 
met, since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT Code C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering system identified 
with code L5962. 
 
You asked the Plan to pre-approve a protective outer surface covering system. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic substitutions and/or additions of 
procedures and components are covered in accordance with the functional level assessment except for code 
L5962 which will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a protective outer surface covering system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a protective outer surface covering system identified with code L5962.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 52442 x6) provided on March 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 52442 is "Cystourethroscopy, with insertion of 
permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List 
separately in addition to code for primary procedure)". 
 
We asked our coding 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 use 
of CPT code 52442 (x6) is not supported by the records provided. Our coding reviewer found that the 
procedure report does not clearly report the total number of additional implants.  The documentation states "a 
total of 7 implants were placed into the prostate.  2 right, 1 deployed without firing, 3 left and 1 median lobe".  
Therefore, the documentation supports a total of 6 implants were performed.  Documentation of "1 deployed 
without firing" cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 52442 x6) provided on March 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the daily skilled services can be 
provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive services at a lower level of care. Admission to a skilled nursing facility for inpatient skilled rehab 
 
 
services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 17, 
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 this was incorrectly coded. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on January 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on July 14, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was preventative. 
You say that is isn't your fault a polyp was removed. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for a diagnostic colonoscopy. The rules say that, if during the 
course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the 
growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be 
billed. A diagnostic colonoscopy falls within the outpatient surgery 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 colonoscopy provided by a participating provider on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network cost share for medical services to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an in-network cost share. You say that the enrollee was referred by her 
physician. The Plan denied your request. The Plan says a leg pump device with accessories is available within 
your network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be 
higher. 
 
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 contract says that enrollees can receive 
care from either a network provider, or an out-of-network provider. We found no exception that would require 
the Plan to pre-approve these services at an in-network rate. Therefore, we decided that the Plan does not have 
to pre-approve an in-network cost share for medical services to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you took too much medication 
because you were in so much pain. You say that the cost is too much and you cannot afford to pay. 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 $200 
copayment each day for days 1 to 8 for Medicare-covered hospital care.  
 
You have been asked to pay a $1,000 copayment for the inpatient stay. ($200/day x 5 days = $1,000). The 
inpatient stay falls within the "Inpatient Hospital 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 the inpatient stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies rendered. 
 
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 A4223 is not payable. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code A4223. This code 
has a status indicator of X and is excluded from Medicare payment. Therefore, we decided that the Plan does 
not have to pay for the infusion supplies rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for 3 specialist office visits (99213, 99214) on 
January 9, May 20, and December 9, 2019. 
 
You asked the Plan to waive the copayment for 3 specialist office visits. You say that in 2019 you were 
approved to be assigned to the Vital Care Program and should be charged a $10 copayment per visit. The Plan 
denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for each of 3 specialist office visits. Specialist office visits fall 
within the "Physician/Practitioner services, including doctor's office visits" benefit category. For 2019, the 
Vital Care Program did not apply to the Plan benefit in which you were enrolled. 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 3 specialist office visits (99213, 99214) on January 9, May 20, and December 9, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy duty wheelchair identified with code 
K0007. 
 
You asked the Plan to pre-approve an extra heavy duty wheelchair. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that an extra heavy duty wheelchair (K0007) is 
covered if the beneficiary weighs more than 300 pounds.  
 
We looked at the file and Medicare rules. Review of the file does not support that your weight is more than 300 
pounds. Based on this information, we decided that Medicare rules for coverage of an extra heavy duty 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy 
duty wheelchair identified with code K0007.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trial of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that the enrollee has not been helped by other 
treatments so this should be allowed. The Plan denied your request. The Plan says this is not a late/last resort 
treatment as no spinal surgery or other treatments have been tried. 
 
The Plan follows Medicare rules. Medicare rules say that SCS placement can be considered as a late, if not last, 
resort treatment for intractable pain when the other criteria listed above have been met.  
 
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 SCS trial. Our reviewer says that 
the requested SCS is not considered medically reasonable and necessary. Our physician reviewer found the 
enrollee has chronic low back pain and scoliosis. She had an Epidural Steroid Injection which gave her only 4 
days of pain relief. She has had Chiropractic Therapy but not formal PT. She had a Psychological evaluation. 
She has not had a surgical evaluation or prior Spine surgery. The request is for a SCS. 
 
The patient does not have an evidence-based indication for an SCS. This procedure would be 
experimental/investigational for this enrollee's condition. Therefore, the request is deemed 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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a trial of a spinal cord stimulator (SCS).