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

 
We decided that the Plan has to pre-approve a convergent hybrid ablation procedure. 
 
You asked the Plan to pre-approve a convergent hybrid ablation procedure. You say that the requested 
convergent hybrid ablation procedure is medically necessary. The Plan denied your request. The Plan says that 
the requested convergent hybrid ablation procedure 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 a convergent hybrid ablation procedure. 
Our reviewer says that the requested convergent hybrid ablation procedure is medically necessary. Our 
physician reviewer found the request is for authorization of the performance--not of the stand-alone, surgical 
MAZE procedure--but of the minimally-invasive procedure incorporating epicardial ablation, performed by a 
cardiac surgeon, in conjunction with an endocardial catheter ablation procedure--performed by a cardiac 
electrophysiologist, often the same day in a combined procedure, or sometimes a few days or weeks later. The 
CONVERGE trial (Delugio 2020) demonstrated the superiority of this hybrid approach combining epicardial 
and endocardial ablation compared with an endocardial catheter ablation procedure alone. While the simpler 
endocardial catheter ablation procedure would be more appropriate for paroxysmal atrial fibrillation, 
proceeding directly to a convergent hybrid procedure would be acceptable because of the poor results of 
endocardial catheter ablation alone, with the frequent need to later carry out a convergent hybrid procedure. As 
a result, authorization for the performance of a convergent hybrid ablation procedure would be considered 
appropriate and reasonable 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 a convergent hybrid ablation procedure have been met. Therefore, we decided 
that the Plan has to pre-approve a convergent hybrid ablation procedure.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99349) rendered by the out-of-network (OON) provider on August 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the home visit for the evaluation and management of an established patient (99349) 
rendered by the out-of-network (OON) provider on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intravascular Ultrasound (IVUS). 
 
You asked the Plan to pre-approve Intravascular Ultrasound (IVUS). You say that the requested Intravascular 
Ultrasound (IVUS) is medically necessary. The Plan denied your request. The Plan says the requested 
Intravascular Ultrasound (IVUS) 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 Intravascular Ultrasound (IVUS). Our 
reviewer says that the requested Intravascular Ultrasound (IVUS) is not medically necessary. Our physician 
reviewer found portions of the small saphenous veins bilaterally are incompetent bilaterally per duplex 
ultrasound scan. The additive clinical value of IVUS as an adjunct to the planned venous angiography has not 
been confirmed by randomized clinical studies. As such, at the current time, IVUS is not medically necessary 
in this enrollees 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 Intravascular Ultrasound (IVUS) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Intravascular Ultrasound (IVUS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the patient has tried and failed 
conservative treatment without relief. You say that this procedure fills a treatment gap for patients that do not 
receive adequate relief from traditional conservative methods and the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is considered 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to show safety 
and efficacy. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee has made 
minimal improvement in function despite intensive daily therapy in the rehabilitation facility for more than 
three weeks. Therapy notes report she has made "minimal progress" toward her goals. Further daily inpatient 
therapy services do not appear to be medically necessary. The enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a 
long-term care facility on a part time basis appear appropriate in this case. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
abdomen provided on September 2, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were charged a $350 copayment for 
an MRI. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $350 copayment for in-network outpatient 
diagnostic testing performed by a provider other than your primary care physician.  
 
The medical record shows you had an abdominal MRI on September 2, 2021. You have been asked to pay a 
$350 copayment for an MRI. An MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies 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 magnetic resonance 
imaging (MRI) of the abdomen provided on September 2, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission.  
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for respiratory failure, congestive heart failure, interstitial lung disease and chronic 
obstructive pulmonary disease. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of this claim. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on October 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and the Plan did not 
authorize any services for this provider for the facility. 
 
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 an office visit (99214) provided on October 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63685, 63655). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that for a spinal cord stimulator to be covered, patients 
have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation 
(Such screening must include psychological, as well as physical evaluation). 
 
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 spinal cord stimulator. Our reviewer 
says that the spinal cord stimulator is not medically necessary. Our physician reviewer found the record shows 
no psychological evaluation prior to this service being 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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator (63685, 63655).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says a skilled nursing facility level of care is recommended by the therapist. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports 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. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service, so this claim 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90833, 99214) provided on 
November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that as per credentialing status 
provider is enrolled and in network with the Plan, and services are payable. You also say that the Plan is 
responsible to pay to the provider. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider, and the Plan did not authorize any services for this provider and the facility. 
 
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 outpatient mental health services (90833, 99214) 
provided on November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the provided documentation does not indicate that the 
services are necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the requested home health services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the home health aide services 
meet Medicare criteria for reasonable and necessary to the treatment of your illness or injury by the skilled 
professional staff. The provided records indicate that you have family available for assistance with activities of 
daily living and wound monitoring. Home health nursing services will reportedly continue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on November 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that services were rendered to the enrollee out of 
medical necessity. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no approved prior authorization. Also, the service rendered was not urgent or emergent. 
  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 an outpatient visit provided on November 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
You asked the Plan to pre-approve Praluent. You say that the requested drug has been shown to assist adults 
with decreased risk of heart attack and stroke. You say that prior to starting Praluent your LDL was 102 and 
that your latest LDL was 55. You say that you have achieved your goal of an LDL of less than 70 from being 
on this medically necessary drug. The Plan denied your request. The Plan says you do not have Part D drug 
coverage through your contract with them. 
 
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 Praluent.  
 Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.