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

 
We decided that the Plan does not have to pre-approve spinal cord stimulator trial. 
 
You asked the Plan to pre-approve spinal cord stimulator trial. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain 
indications. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain which radiates to both legs. 
She has tried physical therapy and a home exercise program. The enrollee takes Tramadol, Tylenol, Lyrica and 
Tizanidine for pain. The enrollee is status post radiofrequency ablation which did not help the pain. The 
documentation does not support that the enrollee has had an adequate trial of conservative therapy. The 
enrollee has not had spine surgery. The documentation does not support that the enrollee has an evidence-based 
indication for a spinal cord stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal cord stimulator trial.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium (75571). 
 You asked the Plan to pre-approve a CT with quantitative evaluation of coronary calcium. You say that this 
service is medically necessary due to underlying circumstances. The Plan denied your request. The Plan says 
this service is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also say that calcium scoring reported 
in isolation is considered a screening service. When performed in association with CT angiography, there is 
neither separate nor additional reimbursement for the calcium scoring. 
 
The test at issue in this appeal is CT angiography with calcium scoring. Medicare does not cover calcium 
scoring as it is considered a screening service, and does not provide separate or additional reimbursement for 
calcium scoring provided in conjunction with CT angiography. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the heart with quantitative evaluation of coronary calcium 
(75571).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services
provided on June 25, 2021.
You asked the Plan to waive the copayment for the ER services. You say that you thought it was at urgent care
and believe it should only a $30 copay. 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 $90
copayment for emergency room visit.
You have been asked to pay a $90 copayment for the ER services. This item/service falls within the emergency
room visit 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 emergency room (ER)
services provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T). 
 
You asked the Plan to pre-approve the cardiac contractility modulation system. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the requested system is considered 
experimental and is non-covered. 
 
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 cardiac contractility modulation 
system. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found cardiac contractility modulation remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 
 
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 cardiac contractility modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not medically stable 
enough to go to a SNF level of care. The Plan denied your request. The Plan says the enrollee can safely 
receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the MyoPro is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH services, you are 
unable to change the wound dressings on your leg properly. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care setting. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a lightweight wheelchair is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is able to walk with a 
walker. The records do not show that she has a mobility deficit that impairs the ability to complete mobility-
related activities of daily living (MRADLs) in the home. The lightweight wheelchair is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the chemotherapy drugs, administration
services and specialist visits provided from September 13, 2021, to October 4, 2021.
You asked the Plan to waive the cost-sharing for the chemotherapy drugs, administration services and specialist
visits. You say that you are requesting review of these bills. The Plan denied your request. The Plan says the
cost-sharing amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare-covered chemotherapy drug and the administration of that drug and a $35 copayment
for in-network services obtained from a specialist.
You have been asked to pay a 20% coinsurance for the chemotherapy drugs and administration services and a
$35 copayment for the specialist visits. These items/services fall within the Medicare-covered chemotherapy
drug and the administration of that drug benefit category, and the in-network services obtained from a specialist
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 cost-sharing for the chemotherapy drugs,
administration services and specialist visits provided from September 13, 2021, to October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient stay, outpatient hospital 
observation service, and specialist visit provided on May 3, 2022, to May 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay, outpatient hospital observation service, and 
specialist 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 $295 
copayment for inpatient hospital care, $225 copayment for outpatient hospital observation service, and $35 
copayment for outpatient hospital service.  
 
You have been asked to pay $295 copayment for inpatient stay, $225 for outpatient hospital observation 
service, and $35 copayment for specialist visit. These items/services fall within the inpatient hospital care, 
outpatient hospital observation service, and outpatient hospital service benefit categories. 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 inpatient stay, outpatient hospital observation service, and specialist 
visit provided on May 3, 2022, to May 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stenting procedures of leg artery. 
 
You asked the Plan to pre-approve stenting procedures of leg artery. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request 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 stenting procedures of leg artery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is nothing in the medical records provided suggesting that there is any 
indication for, or plan to, treat lower extremity arteries. The available documentation does support the medical 
necessity of renal artery angiography and possible intervention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stenting procedures of leg artery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve stenting procedures of leg artery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on May 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 the anesthesia services provided on May 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Freestyle Libre 2 reader device. 
 
You asked the Plan to pre-approve Freestyle Libre 2 reader device. You say that the enrollee established care 
with you on October 4, 2022. The enrollee will continue to get evaluated by you every six months or less. The 
Plan denied your request. The Plan says that this request is not medically necessary as no mention of follow up 
every 6 months for diabetes treatment plan. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 Freestyle Libre 2 reader device. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.  
Our physician reviewer found the enrollee is on 4 shots of insulin a day and adjusts the doses according to their 
blood glucose level. The enrollee is seen often, 3 times in October and frequent follow up is planned. The 
criteria for CGM coverage are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre 2 reader device have been met. Therefore, we decided that the 
Plan has to pre-approve Freestyle Libre 2 reader device.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
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 an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that documentation is lacking in the case record regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The available documentation does not support actual formal surgical ablation 
of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for the enrollee.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you would like this service covered. The Plan denied your request. The Plan says the enrollee's benefit for the requested item or service has already been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows the enrollee's benefit for the requested item or service was exhausted on date of service February 14, 2022. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for the enrollee.
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 requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that the enrollee has functional impairments but there are 
no complex functional deficits specified, a true etiologic diagnosis or active medical comorbidities thus the 
complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. Additionally, evaluating therapists recommend 
skilled nursing facility and the enrollee would not be expected to tolerate 15 hours of therapy per week. 
 
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.