Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
medically necessary. The Plan denied your request. The Plan says home health aide services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
reviewer says that home health aide services are not medically necessary. Our physician reviewer found that 
the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. As such, home health services, including associated HHA services, are not shown to be 
medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vascular study of the aorta, inferior vena cava, iliac 
vasculature, or bypass grafts (93978). 
 
You asked the Plan to pre-approve the vascular study. You say that this study is medically necessary. The Plan 
denied your request. The Plan says a cardiologist needs to work the enrollee up for potential interventions that 
are appropriate before this study can be considered. 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 vascular study. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has a history of hypertension but has no pertinent signs or 
symptoms. As such, there is no evidence to suggest a need to perform the requested aortic ultrasound study.  
 
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 vascular study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vascular study of the aorta, inferior vena cava, iliac vasculature, or bypass grafts 
(93978).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick System. 
 
You asked the Plan to pre-approve the Purewick System. You say that the enrollee needs assistance with 
getting to the bathroom at night. The Plan denied your request. The Plan says the item is not covered by 
Medicare or the Health Plan. 
 
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.  
 
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 the Purewick System.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you do not require intensive rehabilitation and do not require frequent physiatry 
oversight. You do not have complex or specialized rehabilitation needs. 
 
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 reduce the cost share for the outpatient services provided on June 3, 
2022. 
 
You asked the Plan to reduce the cost share for the outpatient services. You say that you are appealing the 
copayment for the stress test because you were told it was $110. 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 20% 
coinsurance for all other Medicare-covered Part B drugs, 20% coinsurance for each Medicare-covered medical 
supply, a $20 copayment for non-radiological diagnostic services, a $110 copayment for radiological diagnostic 
services, and a $35 copayment for services obtained from a specialist.  
 
You have been asked to pay a total cost share of $373.36.  
 
DOS Service Allowed Amount Per 
Contract 
Member Cost 
Share 
June 3, 2022 Myocardial Perfusion 
Imaging (78452) 
$469.28 $110 copayment $110 
June 3, 2022 Stress Test (93017) $36.62 $20 copayment $20 
June 3, 2022 Interpretation of Stress 
Test (93018)  
$14.84 $35 copayment $14.84  
(Less than standard 
$35 copayment) 
June 3, 2022 Injection (J2785) $246 20% coinsurance $49.20 
June 3, 2022 Medical Supply (A9502) $896.62 20% coinsurance $179.32 
Total    $373.36 
 
The myocardial perfusion imaging, stress test and medical supplies fall within the Outpatient Diagnostic Tests, 
Therapeutic Services and Supplies benefit category. An injection falls within the Medicare-covered Part B 
Drugs benefit category. The interpretation of the stress test falls 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 reduce the cost share for the outpatient services provided 
on June 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopic surgery and ultrasound provided on April 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for arthroscopic surgery and ultrasound. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 
 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 arthroscopic surgery and ultrasound provided on 
April 22, 2021, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that you have complex functional impairments however there 
are no active comorbidities, and you are documented as being stable in an outpatient setting thus would not be 
expected to require hospitalization for close medical monitoring in the IRF 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical; with rotator cuff repair 
(CPT code 29827) and arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface 
(Mumford procedure) (29824). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has waited four (4) months for this 
procedure and the injury could result in loss of full function of the arm. The Plan denied your request. The Plan 
says the enrollee's records do not show that they have had any conservative management. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there were no examinations provided for review with subjective and objective findings to 
corroborate the pathology. Detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested CPT 29827- arthroscopic rotator cuff repair and CPT 29824- distal claviculectomy 
(Mumford procedure) in this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroscopy, shoulder, surgical; with rotator cuff repair (CPT code 29827) and 
arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 
(29824).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary CTA of the coronary arteries and bypass 
grafts with contrast, including 3D image postprocessing (code 75574). 
 
You asked the Plan to pre-approve a CTA. You say that a CTA is medically necessary. The Plan denied your 
request. The Plan says a CTA is not medically necessary. 
 
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 CTA. Our reviewer says that the 
requested CTA is not medically necessary. Our physician reviewer found the enrollee has been asymptomatic, 
without any pertinent signs or symptoms. Clinical guidelines for the use of coronary CTA have not been met 
based on review of the submitted clinical documentation. As a result, at this time coronary CTA would not be 
considered medically reasonable and necessary 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 CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a coronary CTA of the coronary arteries and bypass grafts with contrast, including 3D image 
postprocessing (code 75574).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on July 13, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you are disputing the cost share. 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 $295 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $295 copayment for injections. This item/service falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 injections provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found at issue is whether the requested 
authorization for placement of an ILR is medically necessary. While the enrollee has a history of atrial 
fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. 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 follows Medicare rules. Medicare rules say that sacroiliac (SI) joint injections would be considered 
medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is 
considered to be secondary to suspected sacroiliac joint dysfunction. 
 
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 radiofrequency ablation to the SI joint. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found radiofrequency 
of the SI joint is considered experimental/ investigational because of the wide variation in efficacy as published 
in the peer reviewed literature. 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures for the right knee. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the medical records provided do not meet the requirements listed in the LDC for Medicare 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the total knee arthroplasty (CPT code 27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON total knee arthroplasty services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services needed could be provided in-
network. 
 
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 
total knee arthroplasty services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the x-ray examinations provided during 
an emergency room visit on May 21, 2022, billed with codes 73562 and 73590. 
 
You asked the Plan to make additional payment for the x-ray examinations. You say that it is felt that 
additional payment should be made for the two codes at issue. The Plan denied your request. The Plan says the 
payment was made correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Codes 73562 and 73590 have a status indicator of Q1 in the Outpatient Prospective Payment System. This 
means that no additional payment is made when billed on the same date as a code with indicator S, T, or V. 
Payment was made for such a code, meaning that no additional payment is allowed for the imaging. Based on 
this information, we decided that Medicare rules for coverage of the x-ray examinations have not been met. 
Therefore, we decided that the Plan does not have to make additional payment for the x-ray examinations 
provided during an emergency room visit on May 21, 2022, billed with codes 73562 and 73590.