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

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (code 33285). 
 
You asked the Plan to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming. 
You say that insertion, subcutaneous cardiac rhythm monitor, including programming is medically necessary. 
The Plan denied your request. The Plan says the requested insertion, subcutaneous cardiac rhythm monitor, 
including programming does not meet the Medicare coverage criteria and is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 insertion, subcutaneous cardiac rhythm 
monitor, including programming. Our reviewer says that insertion, subcutaneous cardiac rhythm monitor, 
including programming is not medically necessary. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an implantable loop recorder (ILR). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR 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 insertion, subcutaneous cardiac rhythm monitor, including programming have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac 
rhythm monitor, including programming (code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found certainly using ultrasound on a daily basis is not unreasonable, but to 
bill for daily simple simulations and/or image-guided radiation therapy (IGRT) for a technology for which need 
has not been established by published data or supported by consensus guidelines. Billing for daily simulations 
or IGRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy.
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 inpatient rehabilitation is the only option for the 
enrollee to return home safely. The Plan denied your request. The Plan says based on the clinical information 
the enrollee does not meet Medicare criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and accessories to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CPAP device and accessories to be provided by an OON provider. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that 
there are in-network suppliers available to you that can provide the items you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous positive airway pressure (CPAP) device and accessories to be provided by an out-of-network 
(OON) provider.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the services requested can be appropriately provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
Your 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatism-correct function (V2787). 
 
  You asked the Plan to pre-approve astigmatism-correct function (V2787). You say that you will continue to 
have severe eye problems that require correction with eyeglasses after any cataract surgery. You also say that 
laser cataract surgery with lens placement will correct astigmatism. The Plan denied your request. The Plan 
says the requested service is not covered by Medicare or the health plan. 
 
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 does not cover astigmatism-correct function (V2787). 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover routine eye examinations. 
However, astigmatism-correct functions (V2787) are excluded from this benefit. Based on this information, we 
decided that the Plan's rules for coverage of astigmatism-correct function (V2787) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve astigmatism-correct function (V2787).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date of the first period of care in 2022 as required. Based on this information, we find that 
the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from January 7, 2022, to February 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says there is no evidence that the enrollee has 
refractory heart failure or has not failed conventional heart failure management. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart failure 
(CHF) in this patient. 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 patient's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 you just had a leg injury and need help dressing the 
wounds. The Plan denied your request. The Plan says the request is not medically necessary, the services you 
need can be provided safely in other settings, for example, a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code A4557. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code A4557 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #'s 5, 6, 7, 8, 9, 11 and 12 (D7953). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site tooth #'s 5, 6, 7, 
8, 9, 11 and 12 (D7953). The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation - per site tooth #'s 5, 6, 7, 8, 9, 11 and 12 (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
9, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for Physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $25 copayment for specialist office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visits 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 specialist office visit provided on February 9, 2022.
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 you had a fall in May and spent 21 days in rehab that 
was a lower tier of care and was not able to get back to baseline and you need this therapy to regain your 
quality of life and to prevent future problems. The Plan denied your request. The Plan says the request is not 
medically necessary, the services you need can be provided safely in other settings, for example, a skilled 
nursing facility. 
 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CBCT). 
 
You asked the Plan to pre-approve a cone beam computed tomography (CBCT). You say that this service is 
medically necessary. The Plan denied your request. The Plan says the requested imaging is not a covered 
benefit and is denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CBCT).
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 enrollee meets clinical criteria for inpatient 
rehabilitation services and would benefit greatly. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.