Persius/hicric huggingface dataset:
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 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. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on March 7, 2022 with myocardial infarction. She is currently undergoing treatment at 
the acute care hospital (ACH) for cardiovascular disease. There is no evidence that the enrollee requires 
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. The LTACH services are not 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lenses provided on October 22, 2021. 
 
You asked the Plan to pay for the polycarbonate lenses. The Plan denied your request. The Plan says 
polycarbonate lenses are not a covered benefit.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers single vision, lined bifocal and lined trifocal lenses. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to 
pay for the polycarbonate lenses provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation and management 
service (99442) provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you had a phone call with your 
provider to discuss your test results, and you were told by a Plan representative that you would not owe 
anything for this visit. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with 
 
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 $35 
copayment for each telehealth specialist visit.  
 
 You have been asked to pay a $35 copayment for the telehealth visit. Documentation shows that you discussed 
test results and a plan of care with your ophthalmologist on September 21, 2021. It is noted that the total time 
spent during this encounter was 20 minutes. 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 
telephone evaluation and management service (99442) provided on September 21, 2021.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a second home ventilator for a wheelchair. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is a duplicate request. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is medically reasonable and necessary. Our physician reviewer found a second 
ventilator for use with a wheelchair is reasonable and necessary. The enrollee has a generalized neuromuscular 
disease - amyotrophic lateral sclerosis (ALS). The enrollee is fully dependent on a ventilator. A second 
ventilator is necessary for use with the wheelchair for mobility in the home. The other ventilator is for use in 
bed while sleeping. This does not represent a duplicate or backup device, because it is necessary for a 
different  purpose. This is standard care for patients with severe generalized neuromuscular disease. 
 
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 ventilator have been met. Therefore, we decided that the Plan has to pre-
approve a second home ventilator for a wheelchair.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that you were not aware of the prior authorization 
requirement.  You said that these services were provided in good faith and should be paid. The Plan denied 
your request. The Plan says unauthorized, non-plan 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. 
 
Neither your organization nor the referring provider is a network provider with the Plan. 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 lab services provided on November 
22, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. 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 that the enrollee meets Medicare criteria for the requested additional 
accessories. The provided records document that the enrollee has 3+/5 upper extremity strength and is 
independent with grooming, feeding and toileting thus indicating she has adequate upper extremity strength and 
function to operate the wheelchairs power options with their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 3, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like this claim reprocessed 
based on medical records. The Plan denied your request. The Plan says the drug testing services were not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the drug testing services provided on 
September 3, 2021, have been met. In this case, no medical records from the ordering physician were provided 
to support the medical necessity of the rendered drug testing services. Therefore, we decided that the Plan does 
not have to pay for the drug testing services provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous sacroiliac (SI) fusion (27279), completed 
on June 3, 2021. 
 
You asked the Plan to pay for the percutaneous sacroiliac (SI) fusion. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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 pay for the percutaneous sacroiliac (SI) fusion. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation is not evident regarding imaging or radiographic 
evidence supporting a diagnosis of inflammatory sacroiliitis. Multiple other plausible pain generators including 
at the lumbosacral spine are evident. Additionally, the documentation provided for review does not provide objective findings for the right-sided 
sacroiliac joint prior to the surgery. 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 the percutaneous sacroiliac (SI) fusion have not been met. Therefore, we 
decided that the Plan does not have to pay for the percutaneous sacroiliac (SI) fusion (27279), completed on 
June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS wireless pulmonary artery pressure 
monitoring system (33289). 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested item 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 a CardioMEMS system. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains at this time 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 the 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 a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS wireless pulmonary artery pressure monitoring system (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive preventive medicine office visit (99397) 
provided September 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that this is a periodic preventive medicine examination 
with your gynecologist. You had also previously had an annual exam with your doctor that did not include the 
above services. The Plan denied your request. The Plan says this medical benefit has been met for the year. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
 
 
 
 
 
 
 
 Based on review of the file, CPT code 99397 was billed and paid for date of service 10/29/2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive preventive medicine office visit (99397) 
provided September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and 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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex device is considered 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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission and services. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has an acute fracture 
of the vertebral body and requires inpatient hospital care. The Plan denied your request. The Plan says that the 
request for an inpatient hospital stay does not meet Medicare criteria for coverage. The enrollee was seen by a 
neurosurgeon on April 5, 2022, and did not require surgery. A plan was made for outpatient follow up and 
diagnostic testing, and the enrollee was discharged to a skilled nursing facility. Inpatient hospital care is not 
necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented to the emergency department (ED) on April 5, 2022, with 
neck and low back pain following a ground level fall. She was found to have a cervical odontoid fracture. She 
was seen by a Neurosurgeon on April 5, 2022, and did not require surgery. Use of a hard cervical collar was 
recommended and a plan was made for outpatient follow up and diagnostic testing. She received therapy 
services and was discharged for rehabilitation to a skilled nursing facility (SNF) on April 8, 2022. The review 
has determined that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve an acute inpatient hospital admission and services.  
 
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 the VertiFlex Superion Interspinous Spacer (22869). 
 
You asked the Plan to pre-approve the VertiFlex Superion Interspinous Spacer. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 VertiFlex Superion Interspinous 
Spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition. 
 
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 VertiFlex Superion Interspinous Spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the VertiFlex Superion Interspinous Spacer (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for date of service May 18, 
2021. 
 
You asked the Plan to pay for procedure code 99442. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99442 is telephone evaluation and management (E/M) 
service; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the very limited medical 
record does not document that the patient had a telephone encounter.  In addition, the records do not document 
the length of the medical discussion, which is required for billing of this procedure code. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99442 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99442 billed for date of service 
May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
show that 22 or more drug classes were tested. 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 pay for the 
drug testing rendered on June 11, 2021.