Persius/hicric huggingface dataset:
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 the enrollee will receive the appropriate level of care 
in the IRF setting. You say that further delay in care will have a detrimental effect on the enrollee's safety, 
ability to recover to the fullest extent, be discharged to a community setting, and stay in that community 
setting, averting unplanned readmissions. The Plan denied your request. The Plan says the enrollee does not 
require the intensive therapy services that can only be provided at an IRF. The Plan says admission to an IRF is 
not medically necessary at this time. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of 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 excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy (CPT code(s): 15830), excision, excessive skin 
and subcutaneous tissue (includes lipectomy); arm (15836) and excision, excessive skin and subcutaneous 
tissue (includes lipectomy); thigh (15832). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says your records do not show that your pannus (excess skin and fat from the 
abdomen) hangs below your pubis and causes chronic skin irritation and/or infection that has not improved with treatment. The Plan states the procedures to remove excess skin and fat from your arms, and thighs, are to 
improve your appearance and are considered cosmetic. The Plan states cosmetic surgery is not covered by 
Medicare. 
 
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 surgical services. Our physician 
reviewer found the record indicates that you underwent bariatric surgery in the latter half of 2021. The record 
provided does not indicate the that your weight is stable for the most recent six months or that you have chronic 
intertrigo refractory to appropriate medical treatment or functional impairment. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy (CPT code(s): 15830), excision, excessive skin and subcutaneous tissue 
(includes lipectomy); arm (15836) and excision, excessive skin and subcutaneous tissue (includes lipectomy); 
thigh (15832).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee requires frequent duration of 
ventilatory support intermittent use will not be sufficient. The Plan denied your request. The Plan says the 
enrollee's records do not show that they will use this device in a non-continuous positive airway pressure 
(CPAP) or bilevel positive airway pressure (BiPAP) mode. The Plan states the enrollee's needs can be met with 
a different device of a lower-level type. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on February 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says these services were performed and referred by 
out-of-network providers. Out-of-network care is covered only in certain limited circumstances which have not 
been met in this case. 
 
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 requested 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 laboratory services (81479) provided on February 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that this was medically necessary and should be 
paid. The Plan denied your request. The Plan says this was routine OON care that was not pre-approved. 
 
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 requested 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 the office visit provided on July 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan from the 
skull base to mid-thigh, computed tomography (CT) scan of the thorax, and CT scan of the abdomen and pelvis 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a PET scan from the skull base to mid-thigh, CT scan of the thorax, and CT 
scan of the abdomen and pelvis 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 
a positron emission tomography (PET) scan from the skull base to mid-thigh, computed tomography (CT) scan 
of the thorax, and CT scan of the abdomen and pelvis 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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current acute setting. With additional time in the current setting, clinical stability can 
be ensured such that the appropriate lower level of care can be determined. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary 
artery pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence to support the use of this device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with CHF. The clinical study on which FDA approval was based showed 
improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was 
implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. 
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.  Nonetheless, 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 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; single level (Current Procedural Terminology (CPT) code 64490) and injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), cervical or thoracic; second level (64491). 
 
You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied 
your request. The Plan says your request is not medically necessary because the enrollee's records show they do 
not have 80% improvement of the enrollee's pain with the previous injection. 
 
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 injections. Our physician reviewer 
found the diagnostic set of facet blocks did not achieve 80% pain relief. Therefore, the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 
(Current Procedural Terminology (CPT) code 64490) and injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; second level (64491).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET) 
(78608). 
 
You asked the Plan to pre-approve the PET scan of brain. You say that the enrollee needs this. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan of brain. Our reviewer 
says that the requested PET scan of brain is not medically necessary. Our physician reviewer found a PET scan 
is not covered unless there is a differential diagnosis of Alzheimer Disease versus fronto-temporal dementia 
(FTD). The reviewer found that the provided documentation does not indicate such differential. therefore, the 
reviewer found that the requested PET scan of brain 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 the PET scan of brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve brain imaging, positron emission tomography (PET) (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital physician services provided on April 7, 
2022, billed with code 99222. 
 
You asked the Plan to pay for the inpatient physician services. You say that this was billed correctly for 
medically necessary care. The Plan denied your request. The Plan says this claim was billed with an incorrect 
place of service code. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 We find that CPT code 99222 is not supported in the medical record. Specifically, this code is for inpatient 
care. The documentation shows that the enrollee was treated under outpatient observation. There is a more 
appropriate code for this situation. Based on this information, we decided that Medicare rules for coverage of 
the inpatient physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
the inpatient hospital physician services provided on April 7, 2022, billed with code 99222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the emergency room (ER) services 
and self-administered drug provided in an outpatient setting from May 29, 2022, to June 2022. 
 
You asked the Plan to waive the cost share amount for the ER services and self-administered drugs. You say 
that you feel that the self-administered drugs were billed incorrectly. You say that you were not considered 
outpatient when you received these drugs. You also say that you were admitted through the emergency room 
and were not able to bring any of your own medications. 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 $90 
copayment for Emergency Room Services. The rules also say that Medicare Part B generally does not pay for 
self-administered drugs. 
 
You have been asked to pay a $90 copayment for the ER services and self-administered drugs. This 
item/service falls within the Emergency Room 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. Additionally, the drugs you received during the dates of 
service in this case are not among the types which are covered by Medicare Part B. Therefore, we decided that 
the Plan does not have to waive the cost share amount for the emergency room (ER) services and self-
administered drug provided in an outpatient setting from May 29, 2022, to June 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda pen injector. 
 
You asked the Plan to pre-approve the injector. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Saxenda pen injector.