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

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS monitoring system. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that it is felt that there is sufficient 
evidence to support the necessity of this procedure for this enrollee. The Plan denied your request. The Plan 
says this remains an experimental treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this patients 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS monitoring system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing (CPT code 81479) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the test was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the enrollee. The Plan denied your request. The Plan says the services are not deemed a medical necessity 
for the diagnosis used. 
 
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 laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no specific clinical rationale for the requested molecular test. The review has determined that the items/services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing (CPT code 81479) provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day CGM sensor. You say that the sensors should be 
covered. The Plan denied your request. The Plan says you do not meet Medicare criteria for approval of the 
CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14 Day CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 Day continuous glucose monitor (CGM) sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee 
from November 17, 2021, to November 29, 2021. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee was not 
psychiatrically stable and ready to be discharged on November 17, 2021. The Plan denied your request. The 
Plan says the stay was not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our physician reviewer found the admission of this patient does not meet the criteria for November 17, 2022, 
forward as this enrollee was not shown to be a danger to themself or others, delusions, auditory or visual 
hallucinations noted. The enrollee was cooperative/compliant with treatment while not showing any threats the 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided to the enrollee from November 17, 
2021, to November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on April 27, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided on April 27, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on March 
28, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network services provided to the enrollee on 
March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oral device (CPT code E0486). 
 
You asked the Plan to pay for the oral device. You say that the oral appliance is medically necessary. The Plan 
denied your request. The Plan says that the procedure code is not valid for the date of service. 
 
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 oral device. Our physician reviewer 
found the documentation meets the criteria for coverage for an oral appliance for the treatment of Obstructive 
Sleep Apnea (D9948). 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 oral device have been met. Therefore, we 
decided that the Plan has to pay for the oral device (CPT code E0486).  
 
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: 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 you feel that acute rehabilitation is the best option 
for you. The Plan denied your request. The Plan says criteria for this level of care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted on 9/15/2022 after a fall causing a T10 compression 
fracture. As of 9/19/2022, she requires moderate assistance for bed mobility, minimal assist with transfers, and ambulates up to 25 feet with minimal assist and a rolling walker.  
 
She is medically stable with no complexity requiring rehabilitation physician oversight three times per week. 
At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 2, 
2022.  
 
You asked the Plan to pay for these services. . You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network services provided to the enrollee on 
May 2, 2022.
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 it is felt that the enrollee would benefit from IRF 
care. The Plan denied your request. The Plan says IRF criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to an acute hospital on 9/8/22 with hematuria and urinary 
retention. He was found to have acute kidney injury, pancytopenia, and sepsis. After treatment, he is medically stable with debility. Therapy notes show he requires minimal assistance for bed mobility, moderate assist for 
transfers, and can ambulate with minimal assistance of two for 20 feet with a rolling walker. 
 
The records do not show he requires three times weekly consultation with a rehabilitation physician. No acute 
nursing needs are identified. At the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. He needs ongoing therapy in an alternate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on April 15, 
2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network services provided to the enrollee on 
April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 31, 
2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided to the enrollee on 
May 31, 2022.
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 enrollee's needs would be best met at the IRF 
level of care. The Plan denied your request. The Plan says the criteria for IRF care are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee presented to the hospital on 8/30/2022, with right lower extremity cellulitis at the site of a vein harvest. She was treated in the hospital with antibiotics and surgical debridement 
and a wound vacuum device and she discharged to home with home health services on 09/04/2022. She is weak 
and deconditioned and is working with home health nursing and physical and occupational therapy. She is 
walking 30 feet with supervision with a rolling walker and is supervision to minimum assist for transfers and is 
contact guard to maximum assist for activities of daily living. She otherwise is reported to be medically stable 
at home on outpatient medications.  
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patients medical conditions appear 
stable on outpatient medications with no issues that appear to require a physicians evaluation three or more 
times per week. Provided medical records do not explain why the intensive inpatient rehabilitation therapy 
program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the patient. 
 
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: 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 you feel that this level of care is needed. The Plan 
denied your request. The Plan says a lower intensity of care is more appropriate than IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical conditions are stable. There is no clinical need for three-times 
weekly oversight by rehabilitation physicians and no need for acute rehab nursing care. At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested procedure is medically 
necessary due to spondylosis without myelopathy or radiculopathy, lumbar region. The Plan denied your 
request. The Plan says the requested radiofrequency ablation would exceed the amount allowed in a rolling 12 
months. The enrollee would not be eligible for a repeat ablation in the same entire region until 12/7/2022. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation have not been met. Specifically, the records show the enrollee would not 
be eligible for a repeat ablation until December 7, 2022. Therefore, we decided that the Plan does not have to 
pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar 
or sacral, single facet joint (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs and office visit on April 26, 
2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs and office visit. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 
is 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 intravenous, subcutaneous, and biological Part B drugs. Drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services.  
 You must pay $25 copayment for specialty care physician. Covered services include consultation, diagnosis, 
and treatment by a specialist. The provider billed in the amount of $8,145 and the allowed amount is $2,749.28. 
$2,749.28 x 20% = $549.86. $549.86 + $25 = $574.86. Therefore, results in the total cost sharing amount of 
$574.86. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $25 copayment for office visit. Part B 
drugs and office visits fall within the Medicare Part B prescription drugs and Physician/Practitioner services, 
including doctors office visits 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 
Part B drugs and office visit on April 26, 2022.