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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that this procedure is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested procedure 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 RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental therapy due to the wide variation 
in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or necessary 
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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health care visit provided on May 
02, 2022. 
 
You asked the Plan to waive the copayment for a mental health care visit. You say that you should not be 
responsible to pay this. 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 a $40 
copayment for outpatient mental health care. 
 
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for a mental health care visit. This item/service falls within the 
outpatient mental health 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 a mental 
health care visit provided on May 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. 
 
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 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 (CPT code 33289).
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 enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollees needs can be provided safely in 
another setting such as a skilled nursing facility or home with home health services. 
 
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 is medically stable and does not need PMR physician's supervision 3 times a week in an IRF. There were no acute rehab nursing needs identified or documented. At the current 
functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach in an IRF. The document does not support necessity 
for admission to an IRF. While the enrollee may benefit from continued physical therapy and occupational 
therapy, the enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in a 
skilled nursing facility or in-home with family support and services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging services. 
 
You asked the Plan to pre-approve myocardial perfusion imaging services. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage 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 myocardial perfusion imaging services. 
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 carrying out a 
radionuclide stress test. The patient has no cardiac symptoms. There is no documentation that the 
electrocardiogram shows an uninterpretable pattern. There is no evidence provided that would support the need 
for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity 
for the requested cardiac stress testing 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 myocardial perfusion imaging services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant trial. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 pre-approve a spinal cord stimulator implant trial. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of a 
spinal cord stimulator in the immediate post-operatively period is not evidence based. The enrollee does not 
have an evidence based indication for a spinal cord stimulator trial. The request is 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 implant trial have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator implant trial.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says there is not enough medical literature showing that this is safe and helpful, 
this cannot be approved per Medicare rules. 
 
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 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 (CPT code 33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan 
denied your request. The Plan says they are not denying the access to care the Health Plan is denying services 
with an out-of-network provider at the in-network benefit cost share. The Plan states they have a network 
provider that can provide the services the enrollee needs. 
 
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 
the total knee arthroplasty (CPT code 27447) to be provided by an out-of-network provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
records do not show that the enrollee has a history, physical examination, and concordant radiological imaging 
supporting a diagnosis and pathologic cause of lumbar radiculopathy. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided on March 16, 
2022. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that the provider was in-network 
and there is no copayment for physical therapy. 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 a $25 
copayment for outpatient rehabilitation services (physical therapy). 
 
 You have been asked to pay a $25 copayment for the physical therapy. This item/service falls within the 
outpatient rehabilitation services (physical therapy) 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 physical therapy provided on March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip joint replacement surgery (CPT code 27130) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services the enrollee 
needs. 
 
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 
the hip joint replacement surgery (CPT code 27130) to be provided by an out-of-network provider.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be currently unstable and require additional acute care services that can 
safely be administered at the current facility until more stable for transfer. There are no services at the LTACH 
that you require that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as you are not stable for transfer at this time. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom manual wheelchair. 
 
You asked the Plan to pre-approve a custom manual wheelchair. You say that medical records attached to show 
necessity. The Plan denied your request. The Plan says the requested custom manual wheelchair does not meet 
coverage criteria and is not medically necessary under Medicare. 
 
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 custom manual wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a mobility limitation. There is no clear objective gait or 
neuromuscular evaluation indicating that this limitation significantly impairs the ability to complete MRADLs 
and cannot be resolved be a cane or walker. The documentation is not clear that the home is appropriate for a 
wheelchair as there are no objective measurements of the home indicating that your home provides adequate 
access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. 
Without evidence that the manual wheelchair will provide adequate space in the home it is not clear that the 
requested wheelchair will significantly improve participation in MRADLs in the home. The documentation 
does not reveal that you require a custom wheelchair with brakes on the arms and wheels. 
 
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 custom manual wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2022 billed with 
codes 87798, 87150, 87481, 87801, 87653, 87651, 87640, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 19, 2022 billed with codes 87798, 87150, 87481, 87801, 87653, 87651, 87640, and 87500.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric for the enrollee. 
 
You asked the Plan to pre-approve Monoferric. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monoferric. Our reviewer says that 
Monoferric is not medically reasonable and necessary. There is no indication that the enrollee has tried and 
failed Infed (iron dextran) and Venofer (iron sucrose). There is no indication that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found 
that the enrollee's condition does not meet step therapy criteria for Monoferric. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric for the enrollee.