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 the enrollee needs LTACH services to 
treat ongoing medical needs and to facilitate the enrollees ability to return to maximum function. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for LTACH admission. The 
current care setting is adequately meeting the enrollees medical needs and there is no documentation to 
support that an LTACH would better treat the enrollees needs. 
 
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 was admitted to the acute care hospital with buttock pressure ulcers. The 
enrollee was treated with and completed a course of antibiotics. Our reviewer looked at recent medical notes 
and found that the enrollee only requires basic wound care at this stage. While the enrollees wound care is 
complicated by existing conditions (acute kidney injury, sodium deficiency, malnutrition, and urinary tract 
infection (UTI)), the enrollee is otherwise stable and improving.  Our reviewer says additional short-term acute care services can be safely provided at the current facility. There 
are no required services provided at the LTACH that are not already available at the current level of care. It 
would not be clinically beneficial for the enrollee to transfer to LTACH at this time. Therefore, our physician 
reviewer recommends to complete treatment at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable pulse generator (IPG) (0408T), an 
Optimizer SMART CCM device. 
 
You asked the Plan to pre-approve an Optimizer SMART CCM device. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 Optimizer SMART CCM device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found several randomized clinical trials of CCM versus control have also 
been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing 
meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies 
led to FDA approval in 2019, CCM 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. At the current time, I 
would not consider the CCM system to be medically necessary for this enrollee. 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 Optimizer SMART CCM device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an implantable pulse generator (IPG) (0408T), an Optimizer 
SMART CCM device.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for chiropractic manipulative treatment (98941). We decided that the Plan 
does not have to pay for extraspinal chiropractic manipulative treatment (98943) and office visit (99213).  
 
  You asked the Plan to pay for chiropractic manipulative treatment (98941), extraspinal chiropractic 
manipulative treatment (98943) and office visit (99213). You say that the office, individual provider and 
referring provider are participating providers with Medicare. You say that the documentation should be 
reviewed, and the services approved for payment. The Plan denied your request. The Plan says that these 
services are not covered when billed by a chiropractor. 
 
We decided that the Plan has to pay for chiropractic manipulative treatment (98941).  
 
The Plan says this is not a covered service when provided by a chiropractor. CPT code 98941 is for 
manipulative treatment of the spine and is considered a covered chiropractic service when billed by a 
chiropractor. Therefore, we decided that the Plan has to pay for chiropractic manipulative treatment (98941).  
 
We also decided that the Plan does not have to pay for extraspinal chiropractic manipulative treatment 
(98943) and office visit (99213). 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. These services are not manual manipulation of the 
spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulative 
treatment (98943) and office visit (99213). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose receiver/monitor (K0554). 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the medical records provided 
should support the necessity of the requested service. The Plan denied your request. The Plan says the enrollee 
only used insulin twice a day and does not meet the Medicare criteria. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose receiver/monitor 
(K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested service is not medically necessary as the member not 
experienced syncope. 
 
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 requested services are not considered medically reasonable and necessary in this case. The patient has no 
history of atrial fibrillation, nor was atrial fibrillation or any symptomatic cardiac arrhythmias noted on ECG 
monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an 
ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to 
usual care in reducing stroke or systemic embolism among patients at high risk of stroke but without a known 
prior history of atrial fibrillation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 an implantable loop recorder (ILR) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on 
January 12, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment was medically necessary to treat 
the enrollee. The Plan denied your request. The Plan says there is no Medicare benefit for asymptomatic 
patients. 
 
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. 
 
We looked at the file and the rules. The records show the testing was needed to determine whether she is 
affected or known for having a gene mutation. Testing is not reasonable merely on the basis of a particular 
diagnosis. The testing services were requested for screening purposes. Medicare does not cover this testingfor 
screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular 
gene testing provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure (insertion of an interlaminar 
stabilization device). 
 
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex 
is considered 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure (insertion of an interlaminar stabilization device).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine and administration provided on March 
28, 2022. 
 
You asked the Plan to pay for the shingles vaccine and administration. You say that your primary care 
physician recommended this vaccination due to your age. You say that all past vaccinations were covered, and 
you were informed this immunization is covered. The Plan denied your request. The Plan says this vaccination 
is not covered under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine 
and administration provided on March 28, 2022.  
 
  Benefits for the shingles vaccine and administration may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve BRCA testing. You say that you are appealing this denial. The Plan denied 
your request. The Plan says you do not meet the Medicare criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that BRCA testing is non-covered for testing of 
individuals with no personal history of certain types of cancer. 
 
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 BRCA testing. Our reviewer says that 
you do not meet the Medicare criteria for this testing. Our physician reviewer found there is no documentation 
of any signs or symptoms of cancer. BRCA genetic testing is non-covered for testing of individuals with no personal history of cancer because it is considered screening. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and removal of residual tooth roots (cutting procedure) (D7250) provided 
January 28, 2022. 
 
You asked the Plan to pay for the tooth extraction and removal of residual tooth roots. You say that you would 
like these services to be covered. The Plan denied your request. The Plan says these services are not covered 
under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and removal of residual 
tooth roots (cutting procedure) (D7250) provided January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied to laboratory services provided on 
February 15, 2022. 
 
You asked the Plan to waive the deductible applied to laboratory services provided on February 15, 2022. You 
say that you would like this handled through your insurance. The Plan denied your request. The Plan says you 
have a $250 deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to review the cost share applied to falls within the benefit category 
outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $250 deductible which applies to outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time laboratory services was received on February 15, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible applied to laboratory services provided on February 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee was independent previously and 
could return to that level of independence with continued therapy. The Plan denied your request. The Plan says 
the enrollee does not meet the Center for Medicare and Medicaid Services (CMS) criteria for SNF level of care. 
The Plan also says that SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on February 24, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is missing documentation 
required for payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support the medical necessity for the supplies 
provided in this case. Specifically, the medical records do not indicate the ordering provider discussed the need 
for the medical equipment ordered with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the lumbar-sacral orthosis (L0650) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS (33289) device. 
 
You asked the Plan to pre-approve CardioMEMS (33289) device. You say that the device is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested device is not deemed 
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 CardioMEMS (33289) device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. There remains 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 CardioMEMS (33289) device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CardioMEMS (33289) device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biventricular defibrillator placement (33225). 
 
You asked the Plan to pre-approve the biventricular defibrillator placement. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the biventricular defibrillator 
placement. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient documentation to support the medical 
necessity for removal of the dual-chamber defibrillator and replacement with a bi-ventricular defibrillator. 
 
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 biventricular defibrillator placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a biventricular defibrillator placement (33225).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 100 one-
way trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 61 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).