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

 
We decided that the Plan does not have to pre-approve the use of osteopromotive allograft material during an 
approved spinal fusion surgery. 
 
You asked the Plan to pre-approve the allograft material. You say that it is felt that the requested procedures 
are medically necessary. The Plan denied your request. The Plan says the spinal surgery has been approved, 
other than the use of the osteopromotive allograft. 
 
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 allograft material. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found osteopromotive allograft is not medically needed in this case. Traditional allograft 
material will meet the enrollee's needs. Also, the requested material is considered experimental.  
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 allograft material have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the use of osteopromotive allograft material during an approved spinal fusion 
surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on June 4, 2022. 
 
 You asked the Plan to pay for the ambulance response. You say that you should not be responsible for the cost 
since you did not call for the ambulance. The Plan denied your request. The Plan says this service is not 
covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on June 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of postmenopausal osteoporosis.  The Food and Drug 
Administration has not stated that the requested drug as ordered is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug as 
prescribed in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient specialist office visit provided 
on June 23, 2022. 
 
You asked the Plan to waive the copayment for outpatient specialist office visit. You say that you were not 
aware you would be charged for an intern to come out and check you out. 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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for outpatient specialist office visit. This item/service falls within 
the physician/practitioner services, including doctor's office visits 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 outpatient specialist office visit provided on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
left-sided total shoulder reverse arthroplasty and will need inpatient admission after surgery. The Plan denied 
your request. The Plan says there is no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a left-sided total shoulder reverse arthroplasty. 
The record does not document that the treating physician has a reasonable expectation of a length of stay 
spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services, to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that the service should be covered. The 
Plan denied your request. The Plan says there are providers in-network that can perform 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 
physical therapy services, to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found while the enrollee may continue to have some degree of pain and 
impairment with mobility, her progress has plateaued functionally, and her motor strength has remained the 
same. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on June 08, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for a specialist visit provided on June 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
August 4, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that that you are diabetic, 
and this is part of your wellness check. The Plan denied your request. The Plan says a refraction (92015) is not 
covered under the medical benefit. The Plan also says that you do not have vision routine services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for a determination of refractive state (92015) provided on August 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says services can be 
received from providers in the 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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment 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 can safely 
receive care in another setting, such as in your current acute care facility or a long-term care facility with the 
ability to manage ventilators. 
 
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 a CardioMEMS implantable hemodynamic monitor. 
 
You asked the Plan to pre-approve a CardioMEMS implantable hemodynamic monitor. You say that a 
CardioMEMS implantable hemodynamic monitor is medically necessary. The Plan denied your request. The 
Plan says the requested CardioMEMS implantable hemodynamic monitor 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 a CardioMEMS implantable 
hemodynamic monitor. Our reviewer says that the requested CardioMEMS implantable hemodynamic monitor 
is not considered medically reasonable and necessary. Our physician reviewer found that the CardioMEMS 
device was approved by the 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 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 CardioMEMS implantable hemodynamic monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS implantable hemodynamic 
monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient specialist visit provided on 
July 01, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient specialist visit. You say that you have never seen 
a copay like this for a specialist. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for an outpatient specialist visit. This item/service falls within 
the outpatient hospital 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.This copay is partially for the room you were seen in. Therefore, we decided that 
the Plan does not have to reduce the copayment for an outpatient specialist visit provided on July 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ImpediMed L-Dex testing device for the detection 
of lymphedema. 
 
You asked the Plan to pre-approve the ImpediMed L-Dex testing device for the detection of lymphedema. You 
say that the ImpediMed L-Dex testing device for the detection of lymphedema is medically necessary. The Plan 
denied your request. The Plan says the ImpediMed L-Dex testing device for the detection of lymphedema 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 ImpediMed L-Dex testing device 
for the detection of lymphedema. Our reviewer says that the requested the ImpediMed L-Dex testing device for 
the detection of lymphedema is not considered medically reasonable and necessary. Our physician reviewer 
found that the evidence on bioimpedance devices in individuals with known or suspected lymphedema includes 
several prospective studies on diagnostic accuracy and a controlled observational study evaluating clinical 
utility. Relevant outcomes are test accuracy and validity, symptoms, and quality of life. Recent diagnostic 
accuracy studies found a poor correlation between bioimpedance analysis and the reference standard (volume displacement or circumferential measurement). There were no randomized controlled trials (RCTs) evaluating 
the clinical utility of bioimpedance devices in the management of patients with lymphedema or at high risk of 
developing lymphedema. The single prospective comparative study found a significantly lower 
rate of clinical lymphedema in patients managed with bioimpedance devices. Limitations of this study include 
the retrospective design, lack of randomized or blinding, and lack of a systematic method of detecting early or 
subclinical lymphedema in the control group. The evidence is insufficient to determine the effects of the 
technology on health outcomes. The review has determined that the requested ImpediMed L-Dex testing device 
for the detection of lymphedema at issue 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 ImpediMed L-Dex testing device for the detection of lymphedema have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the ImpediMed L-Dex testing 
device for the detection of lymphedema.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary level cardiology care. 
 
You asked the Plan to pre-approve the requested services. You say that you need surgery. The Plan denied your 
request. The Plan says the treatment can be provided by a community-level provider. 
 
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 requested services. Our physician 
reviewer found that there is no specific medical reason for referral to a tertiary level cardiothoracic surgeon. 
The records do not show that you require a tertiary level of care. The requested services 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tertiary level cardiology care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve the ultrasound guided radiation therapy. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that image guided radiation therapy is not supported for the enrollees 
condition. The only modality supported by current guidelines for the enrollees condition is electron beam 
radiation therapy. 
 
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 ultrasound guided radiation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the ultrasound guided radiation therapy (G6001).