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

 
We decided that the Plan does not have to pre-approve removal and replacement of subcutaneous cardiac 
rhythm monitor procedure coded as 33285 and 33286. 
 
 You asked the Plan to pre-approve the replacement of implantable cardiac loop recorder. You say that you are 
requesting the loop insertion procedure given the enrollee's history of prior strokes. The Plan denied your 
request. The Plan says Based on Medicare guidelines, replacement of a device inserted under the skin to 
monitor your heart rhythm (implantable cardiac loop recorder) requested does not meet the requirements for 
approval. 
 
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 replacement of implantable cardiac 
loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of 
replacing the old implantable cardiac loop recorder with a new implantable cardiac loop recorder. The old 
implantable cardiac loop recorder documented the presence of atrial fibrillation. The implantable cardiac loop 
recorder is being requested to allow continued monitoring of the enrollees arrhythmias. Based on current 
guidelines and the documentation provided, there is insufficient clinical evidence to support the medical 
appropriateness and necessity of replacing the enrollees old implantable cardiac loop recorder with a new 
implantable cardiac loop recorder. 
 
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 replacement of implantable cardiac loop recorder have not been met. 
Therefore, we decided that the Plan does not have to pre-approve removal and replacement of subcutaneous 
cardiac rhythm monitor procedure coded as 33285 and 33286.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee's diabetes is well managed with this 
device. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 does not show that the enrollee is using an insulin 
pump or insulin three or more times daily or adjusting dosing due to glucose readings. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre 14-day CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
8, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that only the Veterans Affairs 
should have been billed not the Plan. 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 $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 copayment for an urgent 
care visit provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the specialist telehealth visits provided 
from February 17, 2022, to December 22, 2022. 
 
You asked the Plan to waive the coinsurance for the specialist telehealth visits. You say that you had to use 
telehealth services because you could not be seen in the office. 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 50% 
coinsurance for out-of-network specialist services, including telehealth visits.  
 
You have been asked to pay a total $301.19, which is 50% coinsurance of the allowed amount for each specialist telehealth visit. These items/services fall within the physician/practitioner 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 coinsurance for the specialist telehealth visits provided from February 17, 
2022, to December 22, 2022.
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 services are medically necessary for 
the enrollee to receive physician oversight and skilled therapy services. The Plan denied your request. The Plan 
says the enrollee's needs are being met in the current facility. 
 
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 appears to be improving but is currently unstable and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve infusion services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
services 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 
infusion services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an orthopedic visit. You say that you need to see this out-of-network 
provider because they specifically deal with your health issue, which no other in-network providers do. The 
Plan denied your request. The Plan says there are other providers in-network who you can see for this service. 
 
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 
an orthopedic visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight folding power chair (K0899). 
 
You asked the Plan to pre-approve the folding power chair. You say that the requested power chair is medically 
necessary. The Plan denied your request. The Plan says the requested power chair is not covered for use outside 
your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight folding power chair (K0899).
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 services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH 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 record indicates that the enrollee may have short-term acute medical issues 
but has not been evaluated in a short-term acute care facility. The medical record does not indicate that the 
enrollee requires services that they are not currently receiving but that would only be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prescription drug (S5000) purchased on August 21, 2022, 
outside of the United States (US). 
 
You asked the Plan to pay for the prescription drug. You say that you were on vacation and needed to go to the 
emergency room due to a cellulitis infection in your leg. You also say that you would like to be reimbursed for 
the pharmacy expense you paid. The Plan denied your request. The Plan says prescription medicines are not 
covered out of the country and are excluded from coverage under the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that emergency services furnished outside of the 
United States are only covered when provided in a hospital that meets the definition of an emergency hospital 
and the services meet the criteria of emergency services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the prescription drug have not been met. Therefore, we decided that the Plan does not have to pay 
for the prescription drug (S5000) purchased on August 21, 2022, outside of the United States (US).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1399). 
 
You asked the Plan to pre-approve a power scooter. You say that that you are requesting reconsideration of the 
approval for the power operated vehicle for the enrollee. The Plan denied your request. The Plan says the 
folding power scooter being requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that that the records do not show a home evaluation or that you have a mobility deficit that 
impairs your participation in MRADLs. Your condition can be improved by a walker, cane or manual 
wheelchair and you cannot safely operate the PMD being requested. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein 
(36482). 
 
You asked the Plan to pre-approve the ablation procedure. You say that the records provided should support the 
necessity of the requested service. The Plan denied your request. The Plan says the records do not support that 
the enrollee meets the 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 the ablation procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that there is no current office record. The 
provided records are contradictory showing that the enrollee's wounds on the legs have either healed, or are 
present on the right shin, or are on both heels. Records must also show that the wounds are directly related to 
valves that are not working in the superficial veins of the legs. The records show that the enrollee has other 
reasons for the wounds including kidney failure and heart failure. An ultrasound test also shows that the 
enrollee has valve dysfunction in the deep veins of your legs, and this would not be improved by these treatments. The only vein in the leg that has valve dysfunction that could be improved by this treatment is the 
small saphenous vein on the left leg where there is reflux and an increase in the size of the vein. There is only 
minor reflux in the great saphenous veins, the great saphenous veins are smaller than 5 millimeter and the 
reflux does not extend along the length of the vein which is a requirement. The review has determined that the 
items/services at issue in this case are 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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation therapy of incompetent vein (36482).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the chest. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found as pointed out by the health 
plan a follow-up CT scan per published guidelines is indicated at 3 months after first being detected which 
means that a repeat surveillance CT should be done no earlier than June 3, 2023. At this point in time, the 
request is does not meet criteria for coverage. 
 
 
 
 
 
 
 
 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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan. 
 
 
 You asked the Plan to pre-approve a single-photon emission computerized tomography (SPECT) scan. You say 
that a single-photon emission computerized tomography (SPECT) scan is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for a single-photon emission computerized 
tomography (SPECT) scan. 
 
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 a single-photon emission computerized 
tomography (SPECT) scan. Our reviewer says that the enrollee does not meet criteria for a single-photon 
emission computerized tomography (SPECT) scan. Our physician reviewer found the enrollee had an episode 
of syncope and has a history of atrial fibrillation. He has no cardiac symptoms. The medical records do not 
provide a rationale for the SPECT imaging. There is no documentation that the electrocardiogram (ECG) 
shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing at this time. In summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this 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 a single-photon emission computerized tomography (SPECT) scan have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a single-photon emission 
computerized tomography (SPECT) scan.
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 IRF denial will seriously jeopardize the enrollee's 
life, health, and ability to regain function. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility. 
 
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 documentation shows that the enrollee has complex functional impairments and 
active medical comorbidities. However, based on current therapy notes, the enrollee would not be expected to 
tolerate 15 hours of therapy per week. Specifically, low blood pressure prevented the enrollee from getting out 
of bed or standing activities with occupational therapy. The enrollee had poor pain tolerance with physical 
therapy when their blood pressure was improved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in 
other settings, for example, a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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.