Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested device is considered 
experimental/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 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 the enrollee is a 75-year-old woman with recurrent congestive heart failure (CHF). At 
issue is the medical appropriateness and necessity of implantation of the wireless pulmonary artery pressure 
monitoring system (CardioMEMS) for management of CHF in this enrollee. The CardioMEMS device was 
approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970) provided 
January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 82728, 83540, 83550, 83970) provided January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on March 9, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (0037U) provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence that 
this is late/last resort or if other treatments have been tried and proven unsuccessful. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is subject to the criteria listed 
in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord stimulator trial. Our reviewer says that the requested spinal cord stimulator is not medically reasonable and necessary. Our 
physician reviewer found that the enrollee has lumbar post laminectomy syndrome. The enrollee has had pain 
since a fall in April 2020. They have tried steroid injections with minimal relief. They have also tried an anti-
convulsant and muscle relaxant without much improvement. They have been cleared for this procedure by a 
mental health professional. The enrollee was referred to neurosurgery, but there are no notes available from 
that consultation, nor is there any evidence that there are no further surgical treatments available that could be 
of benefit. There is no documentation of other conservative therapy trials such as acupuncture, massage, 
physical therapy or chiropractic care. In this case, there is insufficient documentation of the failure of 
conservative therapy. Therefore, at this time, 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the positron emission tomography (PET) 
scan (78815) and the Piflufolastat f-18, diagnostic, 1 millicurie (A9595) provided on February 3, 2022. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the item/service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for diagnostic radiology services (computed tomography (CT), magnetic resonance imaging 
(MRI), and a positron emission tomography (PET) scan etc.) rendered by an out-of-network provider. 
Additionally, you must pay a 20% coinsurance for intravenous, subcutaneous, and biological Medicare Part B 
drugs.  
You have been asked to pay $1,870.56 ($889.44 + $981.12). This amount includes the Plans allowed amount 
of $4,447.20 x 20% coinsurance=$889.44 for the diagnostic radiology service rendered by an out-of-network 
provider. Additionally, this amount includes the Plans allowed amount of $4,905.60 x 20% coinsurance= 
$981.12 for the Medicare Part B drug injection provided. 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 coinsurance 
for the positron emission tomography (PET) scan (78815) and the Piflufolastat f-18, diagnostic, 1 millicurie 
(A9595) provided on February 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 1, 2022, to 
March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 1, 
2022, to March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on April 5, 2022. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says the maximum 
benefit has been exceeded. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that you have exceeded the maximum eyewear 
benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for LTACH care have not been met. 
 
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 that the enrollee is an 80-year-old male who was admitted to the acute care hospital 
with COVID-19 pneumonia and acute respiratory failure and acute kidney failure, requiring high flow oxygen 
support, antibiotics, steroids, baricitinub, fluids, and phlebotomy for high hemoglobin. Recent notes describe 
the enrollee with resolved kidney injury and tolerating weaning oxygen with antibiotics completed and stable 
vitals. In this case, the enrollee appears to be more stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. In conclusion, transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 26, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet blocks. 
 
You asked the Plan to pre-approve facet blocks. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD does not support the repeated use 
of diagnostic blocks without a plan to perform radiofrequency ablation (RFA). The request to repeat these 
blocks 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 facet blocks have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet blocks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial gastrectomy with gastrojejunostomy. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence in the medical literature supporting sustained benefit of the 
proposed surgery in the setting of gastroparesis. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial gastrectomy with gastrojejunostomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve a lntracept procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. You also say the lntracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 lntracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
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 care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, 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 SNF care 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for an injection, foot inserts, 
and an x-ray on November 11, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for an injection, foot inserts, and an x-ray. You 
say that you would like to appeal the cost share. The Plan denied your request. The Plan says the cost share 
applied is correct. 
 
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 $25 
copayment for x-rays, a 20% coinsurance for part B drugs, and a 20% coinsurance for covered DME items for 
an injection, foot inserts, and an x-ray. The total cost share owed is $104.08. 
 
You have been asked to pay a $25 copayment for x-rays, a 20% coinsurance for part B drugs, and a 20% 
coinsurance for covered DME items for an injection, foot inserts, and an x-ray.  
 Foot inserts fall within the Durable medical equipment (DME) and related supplies benefit category. 
 
An injection falls within the Medicare Part B prescription drugs benefit category. 
 
An x-ray falls within the Outpatient hospital services 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 and coinsurance for an injection, foot inserts, and an x-ray on 
November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on March 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on March 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 1, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 1, 2022.