Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found if the robotic assisted 
technique is approved as the surgical treatment of choice, the requested CT is necessary per software 
requirements of the robotic assisted technique and would be approved as part of that technique.  If the robotic 
technique is denied the requested CT would still be necessary since the planned surgery is for partial knee 
replacement of the medial compartment only and the choice of arthroplastiic device would be assisted by the 
CT for modeling. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that medical records have been 
submitted to support medical necessity. The Plan denied your request. The Plan says an implantable loop 
recorder is considered reasonable and necessary when syncope (fainting) is thought to be cardiac related and an 
external Holter monitor (heart rate and rhythm monitor) has been tried and failed to detect an abnormal heart 
rhythm. Therefore, the request to overturn the denial of cardiac rhythm monitor is not granted. 
 
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 an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. 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 ILR. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollee'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 an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64448-RT) provided on August 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 64448 is not supported in the medical record. Specifically, the records 
show that the procedure was performed on the left side and was billed with a left-sided diagnosis code. The 
billed code 64448 was appended with modifier RT. It is inappropriate to bill a left-sided procedure with 
modifier RT. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (64448-RT) provided on 
August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 29, 2022, to September 
07, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting this be reviewed and processed 
for payment. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 29, 2022, to September 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incobotulinumtoxinA (Xeomin). 
 
You asked the Plan to pre-approve Xeomin. You say that oral medications did not adequately control the head 
tremor. The Plan denied your request. The Plan says the requested use is not covered. 
 
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 Xeomin. Our physician reviewer found 
that the enrollee has a diagnosis of head tremor in the setting of small fiber neuropathy. The FDA 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 Xeomin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve incobotulinumtoxinA (Xeomin).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an extracapsular cataract removal. You say that you are requesting a gap 
exception for cataract surgery for the enrollee. The Plan denied your request. The Plan says the requested out-
of-network provider is not contracted in the enrollee's network. The enrollee must use in-network providers to 
receive services and care from the Plan. The requested services are available within the enrollee's 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 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 
an extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) to be provided by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing (80307) and definitive drug 
testing (G0481) provided November 16, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provider chose to send the test to your 
lab in an effort to devise the treatment plan that they felt was best for their patient. The Plan denied your 
request. The Plan says this service does not meet coverage requirements. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. The test requisition form 
was not signed by the ordering provider and the order was a predetermined standing order which was unsigned. 
Therefore, we decided that the Plan does not have to pay for the presumptive drug testing (80307) and 
definitive drug testing (G0481) provided November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair. 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. 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 power mobility devices are 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 pre-approve a group 2 standard power wheelchair. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's 
condition does not meet criteria for a group 2 power 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 a group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs to get stronger before returning 
home. The Plan denied your request. The Plan says continued SNF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that the enrollee had functional or clinical status 
change; thus, skilled therapy or nursing would be medically appropriate. However, after March 14, 2023, there 
is no recommendation for or documentation to support continued daily skilled services on an inpatient basis in 
a skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that this is necessary to keep your knee from 
bowing sideways when you walk. The Plan denied your request. The Plan says the requirements for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control is covered if the beneficiary has had recent 
injury to or a surgical procedure on the knee(s). Knee orthoses are also covered for a beneficiary who is 
ambulatory and has knee instability 
 
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 knee orthosis. Our reviewer says that 
the requested knee orthosis is not medically necessary. Our physician reviewer found the submitted records do 
not document recent injury, surgery, or instability. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1852).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from November 8, 2022, to November 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are living on a 
fixed income. 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 $250 
copayment per day, days 1 to 6, for in-network inpatient care. 
 
You have been asked to pay a $1500 copayment for the inpatient hospital stay ($250 x 6 days = $1500). This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided by an in-network provider from November 8, 2022, to 
November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you are requesting reconsideration stating this 
device will decrease respiratory exacerbations, expensive hospitalizations, and worsening symptoms for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because records do 
not show that the enrollee has a diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. Chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of 
bronchiectasis do not meet this criterion. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found provided records in this case do not document 
a diagnosis of cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency 
chest wall oscillation device may be covered. The enrollee presently uses a mechanical in-exsufflation device 
(E0482) and plans to continue to do so. Provided records in this case document failure of multiple inhaled 
treatments but make no mention of use of guaifenesin for the management of her retained secretions. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Surgery
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 this is medically necessary. The 
Plan denied your request. The Plan says this is contraindicated for the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections should not be performed 
when contraindicated, including in cases with a suspected or active localized spinal infection or a significant 
systemic infection. 
 
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 requested epidural steroid injection is not reasonable and necessary. Our physician 
reviewer found the records show that there is concern the enrollee has an active infection. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If there is chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive airway 
pressure (BiPAP) during sleep. Average volume-assured pressure support (AVAPS) can be provided with 
BiPAP if necessary. Medicare does not cover a home ventilator for the treatment of obesity hypoventilation 
syndrome (OHS), or when used with settings that can be provided with BiPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplied 
provided on July 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the item was for use during surgery. The Plan 
denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The file shows the services at issue were provided at an ambulatory surgical center. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device and related supplied provided on July 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T and C1825). 
 
You asked the Plan to pre-approve the device. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Barostim Neo device is considered unproven and is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the 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 an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Barostim Neo device (0266T and C1825).