Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 29, 2020, to May 2, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the medical records support the inpatient level of care. The Plan denied your request. The Plan says that the inpatient services were not medically necessary.

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. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 29, 2020, to May 2, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart
failure) (CPT Codes 33289 and C2624).

You asked the Plan to pre-approve the CardioMEMS device. You say that the services are necessary. The Plan
denied your request. The Plan says the services are 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 CardioMEMS 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, in my opinion, 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 CardioMEMS device have not been met. Therefore, we decided that the
Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart failure) (CPT Codes
33289 and C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 14, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you received a card that said office visits would be covered in full for the rest of the year. You say that you assumed it included all office visits so this should be covered 100%. 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 $20 copayment per specialist office visit. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was with a specialist. The Plan says that only primary care physician copayments will be waived. 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 office visit provided July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the standard wheelchair (CPT Code K0001) and cushion (E2601).
You asked the Plan to pre-approve the DME. You say that the wheelchair and cushion is medically necessary. The Plan denied your request. The Plan says they do not see if the enrollee's home is suitable for this. The Plan states they asked for this information and received information from a physical therapist. The Plan states there is no information about the enrollee's home and whether their home can accommodate the requested wheelchair.
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 DME. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the requirements listed in Medicare's National Coverage Determination/Local Coverage Determination: Manual Wheelchair Bases (L33788). The provided medical records contain no information about the enrollee's home and whether their home can accommodate the requested wheelchair. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the standard wheelchair (CPT Code K0001) and cushion (E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on April 21, 2020.
You asked the Plan to pay for the wound care supplies (A6021, A6213, A6251, A6252). You say that the physician ordered these supplies. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order for the supplies provided in this case. There is no physician order indicating the billed supply code and the units. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be stabilizing but requires additional acute care services to continue to wean from high flow oxygen, which can safely be administered in the current setting. The patient does not require services at the LTACH that are not already available at the current setting. There are no services at the LTACH that the patient requires that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided June 22, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you purchased the hearing aids from Elite Hearing 
Aid, an out-of-network provider, because they have rechargeable batteries. The Plan denied your request. The 
Plan says the hearing aids were obtained from a non-plan provider and not eligible for coverage. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only purchased from an in-network hearing aid provider.  
 
We looked at this file and the Plan's rules. The case records indicate that the hearing aids were purchased from 
Elite Hearing Aid, an out-of network provider, and not from an in-network hearing aid 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart 
failure) (CPT Codes 33289 and C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are 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 CardioMEMS 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart failure) (CPT Codes 
33289 and C2624).
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 June 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous immune globulin (IVIG) rendered on April. 
 
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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records were limited to an 
order form. There is no other clinical information. IVIG is not FDA-approved for the treatment of 
neuromyelitis optica (NMO). There is no information regarding the etiology of the enrollee's NMO. The 
services were 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 pay for the intravenous immune globulin (IVIG) rendered on April.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided. 
 
You asked the Plan to pay for the testing services. You say that the diagnosis from the testing enabled the 
provider to determine the optimal treatment pathway. The Plan denied your request. The Plan says there are no 
progress notes to determine the clinical utility of the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. In 
this case, there is insufficient documentation to show that the results of the testing were needed to determine a 
specific diagnosis or treatment strategy. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 
testing provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93308). 
 
You asked the Plan to pre-approve transthoracic echocardiography. You say that this is necessary to see if the 
enrollee has improved. The Plan denied your request. The Plan says there is no documentation to show a repeat 
test is necessary. 
 
The Plan follows Medicare rules. Medicare rules say that evaluation of left ventricular function with prior 
ventricular function within the past year with normal (such as prior echocardiogram, left ventriculogram, 
SPECT, cardiac MRI) in patients in whom there has been no change in clinical status 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 transthoracic echocardiography. Our 
reviewer says that the requested TTE is not medically necessary. Our physician reviewer found an 
echocardiogram performed on August 14, 2020 revealed stable left ventricular dysfunction with a systolic 
ejection fraction of 40-45%. 24 hour holder monitor in September 2020 following ablation in August 2020 
revealed significantly improved premature ventricular complex burden. There is no documentation of any 
change in clinical status that would warrant a repeat echocardiogram at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93308).
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 this should be covered. The Plan denied your 
request. The Plan says the enrollee's condition is stable and there is no need to hospital level medical care or an 
intensive rehab program. 
 
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 enrollee is a male with a history of Parkinson's disease who underwent a spinal 
procedure on 10/29/2020. He presented with fever, confusion and purulent drainage from incision site. CT of 
the head was done which was negative for acute process. CT of the lumbar spine with contrast shows 
postoperative changes with limited assessment for abscess. He was treated with IV Vancomycin and Zosyn 
which was discontinued on 11/29 with no remaining fever, elevated white blood cells and a negative blood 
culture.  
 
The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not 
currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from 
 
 
multiple therapies such as physical and occupational therapy but the documentation does not support that the 
patient's functional status requires an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that for a knee orthosis to be covered there must be 
documentation of objective joint laxity, instability, recent injury or surgery to the knee. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not show any of the covered indications for the knee orthosis.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on December 19, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says they will pay 
for one annual wellness exam every 12 months. 
 
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 annual wellness visits 
are covered once every 12 months.  
 
We looked at the file and the rules. The documentation shows that you received an annual wellness visit on 
September 17, 2019. You also received an annual wellness visit on December 19, 2019. This service is only 
covered once every 12 months. Based on this information, we decided that the rules for coverage have not been 
met.  Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on 
December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the implant (D6010), the initial 15 minutes of 
deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drug 
(D9610) provided on January 6, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that the services you received were 
medically necessary. You also say that the services should be covered under your medical benefit. The Plan 
denied your request. The Plan says the services you received are dental in nature. The Plan says that routine 
dental services are not covered by your medical benefit. The Plan also says that your comprehensive dental 
services do not cover the services that you received either. 
 
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. 
 
 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the 
services you received are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to reimburse you for the implant (D6010), the initial 15 minutes of deep sedation (D9222), the 
additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drug (D9610) provided on 
January 6, 2020.