Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cataract surgery services (66984) 
provided on November 4, 2021, and November 11, 2021. 
 
You asked the Plan to waive the copayments for cataract surgery. You say that you paid $350 out-of-pocket for 
each of these surgical procedures, and you feel that you should be reimbursed by the Plan. The Plan denied 
your request. The Plan says these claims were processed correctly, and your copayments were assessed in 
accordance with your contract. You are responsible for a $350 copayment for outpatient surgery services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for each Medicare-covered outpatient surgery service.  
 
 You have been asked to pay a $350 copayment for each cataract surgery procedure. Cataract surgery falls 
within the Medicare-covered outpatient surgery 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 
copayments for the cataract surgery services (66984) provided on November 4, 2021, and November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is stable and suitable for transfer to an 
IRF. You say that a skilled nursing facility is not an appropriate safe level of care at this time, as she will need 
more frequent physician visits and frequent monitoring and interventions. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the 
services needed in another setting. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs were identified or 
documented in the record. At the current functional level, the enrollee is more appropriate for a skilled nursing 
facility (SNF) rehabilitation, and does not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. An IRF admission is 
not medically necessary based on medical stability, lack of medical complexity, and lack of rehabilitation 
nursing needs. Documentation does not support the necessity for admission to an IRF. While the enrollee may 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided at a 
lower intensity and alternate setting such as in an SNF. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the CardioMEMS implant for the enrollee. 
 
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this procedure is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 implant. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the CardioMEMS Heart Failure (HF) System is indicated for wirelessly measuring and monitoring 
pulmonary artery pressure and heart rate in NYHA Class II or III heart failure patients who either have been 
hospitalized for heart failure in the previous year and/or have elevated natriuretic peptides. The hemodynamic 
data are used by physicians for heart failure management with the goal of controlling pulmonary artery 
pressures and reducing heart failure hospitalizations. The documentation supports that the CardioMEMS heart 
failure system is medically reasonable and necessary for the enrollee in this case, and that the indications for 
the HF system have been 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 the implant have been met. Therefore, we decided that the Plan has to pre-
approve the CardioMEMS implant for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves 
(CPT 64635). 
 
You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves. You say that the 
services are medically necessary because she is unable to walk and needs this injection. She reports she is not 
able to get up and move around and is in pain 24 hours a day despite pain medication. The Plan denied your 
request. The Plan says he requested injections are not medically necessary and do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 destruction of lower or sacral spinal 
facet joint nerves. Our reviewer says that the requested destruction/RFA of lower or sacral spinal facet joint 
nerves is not medically necessary. Our physician reviewer found the enrollee did not achieve at least an 80% 
improvement of pain or improvement in activities of daily living for a sustained period of time. The review has 
determined that the requested destruction/RFA of lower or sacral spinal facet joint nerves does not meet the 
Medicare LCD coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction of lower or sacral spinal facet joint nerves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet 
joint nerves (CPT 64635).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the patient can be managed at a lower level 
of 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for altered mental status and pneumonia. Their medical problems are stable and there are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts. 
 
You asked the Plan to pre-approve foot inserts. You say that the inserts will help your feet when you walk. The 
Plan denied your request. The Plan says the orthotics are not being used as an integral part of a covered brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
We looked at the file and the rules. The file does not show that you suffer from diabetic foot disease, or wear a 
leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee is unable to obtain finger 
sticks due to medical conditions. The Plan denied your request. The Plan says the enrollee does not meet the 
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. In this case, there are no recent medical records to indicate that the 
enrollee uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage 
based on the blood glucose testing results, and has had a current 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick female external catheter (A4328). 
 
You asked the Plan to pre-approve PureWick catheter. You say that please review and reconsider this case. The 
enrollee has benefitted from using the PureWick female external catheter in the past and granting approval for 
continued use would improve the enrollee's quality of life. The Plan denied your request. The Plan says the 
requested service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PureWick catheter have not been met. Therefore, we decided that the Plan does not have to pre-
approve PureWick female external catheter (A4328).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy with biopsy (45380-51) and a colonoscopy with 
directed submucosal injection(s) (45381) provided on September 25, 2021. 
 
You asked the Plan to pay for the colonoscopy services. You say that these services were necessary and are 
appropriate as billed. The Plan denied your request. The Plan says the documentation indicates that the 
colonoscope in both services failed to reach the junction of the cecum. There is a more appropriate modifier 
which should be appended to this bill for the incomplete colonoscopy services. These services are not 
supported as billed 
 
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 45380 is colonoscopy, flexible; with biopsy, single or multiple and the definition of CPT code 45381 is 
colonoscopy, flexible; with directed submucosal injection(s), any substance. 
 
We asked our coder 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 colonoscopy services. Our reviewer says that these 
services are not supported as billed. Our reviewer found that in the case of 45380, the record indicates that the 
scope was able to be passed beyond the hepatic flexure but not beyond this because of a packed right colon of stool. In this case, the cecum was not reached, and therefore an appropriate modifier should be appended. In the 
case of 45381, the documentation shows that the scope was also able to be passed beyond the hepatic flexure 
but not beyond because of the right packed colon. In this case as well, the cecum was not reached, and 
therefore an appropriate modifier should be appended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the colonoscopy services have not been met. Therefore, we decided that the 
Plan does not have to pay for colonoscopy with biopsy (45380-51) and a colonoscopy with directed 
submucosal injection(s) (45381) provided on September 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF is not medically necessary and you can be managed at a lower level of 
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
wound infection at the site of recent cervical spine surgery. Your medical problems are stable and there are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the supplies were covered with your 
previous plan. The Plan denied your request. The Plan says the request is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
We looked at the file and the rules. While incontinence supplies may be appropriate in this case, neither the 
Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-
approve incontinence supplies.
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 would benefit from an IRF admission. 
The Plan denied your request. The Plan says in this case IRF care is not considered medically reasonable or 
necessary based on Medicare guidelines. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on April 26, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you already paid your copay. The 
Plan denied your request. The Plan says the copayment applied 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 $75 
copayment for Medicare-covered diagnostic services, including ultrasounds.  
 
 
 
 You have been asked to pay a $75 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the ultrasound provided on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pharmacogenomic testing (81401, 81225, 81227, 81226, 
81230, 81231, 81232, 81249, 81241, 81249, 81373, 81291, 81408, 81328, 81335 and 81355) provided on 
March 8, 2021. 
 
You asked the Plan to pay for the Pharmacogenomic testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this testing was not billed appropriately. 
 
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 Pharmacogenomic testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have a condition where clinical evaluation has determined the 
need for a medication that has a known gene-drug interaction(s) for which the test results would directly impact 
the drug management of the enrollees condition. The requested testing does not meet evidence standards for 
genetic testing as evaluated by a scientific, transparent, peer-reviewed process and determined to demonstrate 
action ability in clinical decision making by CPIC guideline level A or B1; or is listed in the FDA table of 
known gene-drug interactions where data support therapeutic recommendations or a potential impact on safety 
or response or the FDA label. There are limitations, as listed in the LCD, which would prevent coverage of this 
testing. 
 
 
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 Pharmacogenomic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Pharmacogenomic testing (81401, 81225, 81227, 81226, 81230, 81231, 
81232, 81249, 81241, 81249, 81373, 81291, 81408, 81328, 81335 and 81355) provided on March 8, 2021.