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

 
We decided that the Plan does not have to waive the copayments for the periodic oral evaluation (D0120), 
photographic images (D0350), and a cleaning (D1110) provided on August 9, 2022. 
 
You asked the Plan to waive the copayments for the dental services. You say that there are no copayments 
listed for the dental services you received. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
  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. 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 $15 copayment for per service 
during the visit for covered routine dental services. For the periodic oral evaluation there was a copayment 
charge of $15. For the cleaning there was a $15 copayment. For the photographic images the total amount 
allowed was $13.79 which is less than the $15 copayment; therefore $13.79 was charged as a copayment. The 
total amount for all copayments was $43.79 ($15 copayment + $15 copayment + $13.79 copayment). 
 
You have been asked to pay a $43.79 copayment for the dental services. This item/service falls within dental 
services 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 periodic oral 
evaluation (D0120), photographic images (D0350), and a cleaning (D1110) provided on August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to go to rehab due to breaking your hip. 
You say you are in a lot of pain and are frustrated this is being denied. You say your doctor states that you need 
to go to rehab. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 clinical documentation shows that you had complex functional impairments 
that have mostly resolved and almost all listed therapy goals have been met. There are no active medical 
comorbidities. The complexity of your documented nursing, medical and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of carotid sinus Baroreflex activation 
device, total system (0266T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are submitted this request for 
redetermination of the enrollee's implantation of a carotid sinus baroreflex system for heart failure. The Plan 
denied your request. The Plan says this procedure is considered experimental and investigational. There is not 
enough clinical evidence in the peer reviewed medical literature to show that this procedure improves long 
term health outcomes for people. 
 
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 the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation of carotid sinus Baroreflex activation device, total system (0266T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left shoulder radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic pain in his left 
shoulder from a rotator cuff tear. The use of RFA for shoulder pain is considered experimental/investigational 
in nature and not medically necessary at this time. 
 
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 left shoulder radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve the RFA. You say that you have had significant relief from the first two 
procedures. You say that you do not understand why this service is not covered too. The Plan denied your 
request. The Plan says the requested 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 pre-approve the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested procedure is considered experimental. Therefore, the reviewer found that the RFA is 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that you and your doctor decided that injections were 
the best procedure to treat your pain. You say that you have had this procedure done before. You also say that 
you had 70 to 75% success rate of a little over three to four months. The Plan denied your request. The Plan 
says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
shows that you had 70% pain relief for only a few days after your first injection. Therefore, the reviewer found 
that the request for a repeat ESI is 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a carotid sinus baroreflex system 
coded as 0266T and C1825. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that you request redetermination of the 
enrollee's implantation of a carotid sinus baroreflex system for heart failure. The Plan denied your request. The 
Plan says the Barostim Neo device is unproven and not medically necessary for treating heart failure due to 
insufficient evidence of safety and efficacy. 
 
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 the Barostim Neo device have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve the implantation of a carotid sinus baroreflex 
system coded as 0266T and C1825.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve ablation (Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has failed non-operative 
treatment. You also say that this procedure is the best solution for the enrollee's pain. The Plan denied your 
request. The Plan says the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates there are multiple plausible pathologic sources 
of the enrollee's significant pain generation. The reviewer found that the documentation is lacking regarding 
reasonably detailed and evidenced findings supportive of the spinal vertebral bodies as being the overwhelming 
primary generators of the enrollees chronic persistent pain. Therefore, the reviewer found that the requested 
Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve nerve ablation (Intracept procedure) (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the CGM supply allowance. You say that you are appealing the denial to 
your DME request for your Freestyle Libre sensors. The Plan denied your request. The Plan says the enrollee is 
not on insulin and 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. 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 CGM supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a supply allowance used with a therapeutic 
CGM device (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin, (E0784). 
 
You asked the Plan to pre-approve an external infusion pump. You say that the enrollee has renal disease with 
an abnormal CPAP level. You also say that you were advised you would benefit from an insulin pump. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that continuous subcutaneous insulin infusion (CSII) and 
related drugs/supplies are covered as medically reasonable and necessary in the home setting for the treatment 
of diabetic patients who: (1) either meet the updated fasting C-Peptide testing requirement, or are beta cell 
autoantibody positive; and, (2) satisfy the remaining criteria for insulin pump therapy. 
 
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 external infusion pump. Our 
reviewer says that the requested external infusion pump is not medically necessary. Our physician reviewer 
found the records do not show that your C-peptide level was less than or equal to 110 percent of the lower limit 
of normal of the laboratory's measurement method. The reviewer found that you did not have a fasting blood 
sugar obtained at the same time that was less than or equal to 225 mg/dL. The reviewer also found that your 
renal function is normal, and you do not have a diagnosis of Type I diabetes. Therefore, the reviewer found that 
the requested external infusion pump is not medically necessary in this case. 
 
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 external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external ambulatory infusion pump, insulin, (E0784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that you had atrial fibrillation (AFIB). You say that you 
received an ablation and need a heart monitor to see why you have AFIB attacks. You say that you have gone 
to the hospital for your heart rate. You also say that the heart monitor will help assist tracking your heart. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
memory loop recorder (MLR). 
 
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 ILR. Our reviewer says that the 
requested ILR is not medically necessary. Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable cardiac monitor (ICM). Therefore, the reviewer found there is insufficient documentation to 
support the medical necessity for insertion of an ICM in this case. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation for the 
enrollee to regain maximum function. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for admission to an IRF. Skilled therapies at home or at a skilled nursing facility may be 
approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on August 04, 2022, 
to August 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for per day for days 1-5 and $0 after day 5 for inpatient hospital stay. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were four days. 4 x $200 = $800. Therefore, results in the total 
cost sharing amount of $800. 
 
 
 
You have been asked to pay a $200 copayment per day for inpatient hospital stay. This item/service falls within the inpatient hospital care 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 inpatient 
hospital stay on August 04, 2022, to August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee has had a workup including 
echocardiogram and 3-week event monitoring showing no atrial fibrillation. You say the enrollee has had 
symptoms of fatigue and the urge to fall. You also say that the ILR is necessary to monitor for possible occult 
atrial fibrillation as a cause of the enrollee's TIA and above symptoms. The Plan denied your request. The Plan 
says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that n ILR is used when syncope is thought to be cardiac-
related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom memory 
loop recorder (MLR). 
 
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 ILR. Our reviewer says that the 
request for insertion of an ILR is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee has a history of atrial fibrillation, nor were any significant cardiac 
arrhythmias noted on electrocardiogram (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. Therefore, the reviewer 
found that the request for insertion of an ILR would not be medically reasonable and necessary in this case.  
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).