Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 4, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a counselor mental 
health provider does not meet the licensure criteria per Medicare guideline to bill these psychiatric service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided from January 4, 2022, to  
January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 18, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says in the absence 
of clinical information, medical necessity and coverage cannot be determined. With the information we have, 
we cannot determine how the member came to the servicing provider, or whether the services are medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physician's services have been met. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve placement of a leadless pacemaker. 
 
You asked the Plan to pre-approve the leadless pacemaker procedure. You say that the enrollee is at increased 
risk for infection, skin breakdown, and possible skin erosion with the traditional implantable pacemaker. You 
also say that the requested leadless pacemaker would be a better option for the enrollee. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that leadless pacemakers are covered in prospective 
longitudinal studies. Medicare has approved such a study reviewing claims data which automatically enrolls 
patients who receive the Micra leadless pacemaker. 
 
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 leadless pacemaker procedure. Our 
reviewer says that the criteria for the requested pacemaker have been met. Our physician reviewer found at 
issue is the medical appropriateness and necessity of implanting a leadless pacemaker, instead of a traditional 
pacemaker with an intravascular lead, in a patient who meets criteria for a permanent pacemaker based on 
documented complete atrioventricular block with prolonged pauses on submitted implantable loop recorder 
tracings, which are reviewed and confirmed. The advantage of the leadless pacemaker is avoidance of an 
intravascular lead, while the limitation is the inability to allow pacing in the atrium, as well as the inability to 
remove and replace the generator at the time of battery depletion, roughly every 10 years, with a need to place 
a new unit at time of battery depletion. However, this patient's advanced age makes her a suitable candidate, as 
opposed to a younger person, for which a leadless pacemaker might not be appropriate. 
 
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 leadless pacemaker procedure have been met. Therefore, we decided that the 
Plan has to pre-approve placement of a leadless pacemaker.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80307, G0480) provided on May 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says with the provided information, the Plan cannot determine how the enrollee 
came to the servicing provider, or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. 
Records were needed from the provider to determine how the enrollee came to the servicing provider or whether the services are medically necessary. The Plan made multiple attempts to obtain the needed medical 
records from the provider without success. Therefore, we decided that the Plan does not have to pay for the lab 
services (80307, G0480) provided on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulation (PNS) System. 
 
You asked the Plan to pre-approve a SPRINT PNS System. 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 a SPRINT PNS System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational approach to knee pain as there is 
insufficient literature to support its use. Therefore, the request is deemed not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SPRINT PNS System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulation (PNS) System.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile trip limit. 
 
You asked the Plan to pre-approve the additional miles for routine transportation beyond the Plan's 50-mile trip 
limit.  
You say that the enrollee needs the additional 15 more miles for a total of 65 to be able to go the physician 
office. The Plan denied your request. The Plan says the requested trips exceed the Plans mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested transport 
exceeds the 50 miles. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's 50-mile trip limit.
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 you are a high fall risk, cannot walk without 
assistance and have trouble breathing. You have no one at home who can assist you. The Plan denied your 
request. The Plan says your records show that it is not reasonable to expect that you will be able to safely 
participate in, or fully benefit from, the intensity of services of an IRF. You may safely receive the services 
needed in other settings, for example, a skilled nursing facility, home with home health services or perhaps 
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 is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility and 
may safely receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day (99239). 
 
You asked the Plan to pay for hospital discharge day. You say that you do not agree with the Plan's denial. The 
Plan denied your request. The Plan says that it was determined that this denial should be overturned, but the 
claim could not be processed before the appeal time frame expired. As such, the case was forwarded to 
Maximus for review. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It was noted that the denial was to be overturned, but the remittance submitted 
shows that payment was again denied. Without a valid denial rationale being offered for the original claim nor 
the reprocessed claim, we find that the denial of payment is not supported. Therefore, we decided that the Plan 
has to pay for hospital discharge day (99239).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman left atrial appendage occlusion device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 there is no apparent contraindication to anticoagulation. As such, guidelines would not support 
implantation of a left atrial appendage closure device (LAAC) in this setting. In summary, LAAC placement 
would not be considered reasonable or medically 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 the Watchman left atrial appendage occlusion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 19, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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 $350 
copayment for Outpatient surgery. 
 
You have been asked to pay a $350 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 surgery 
provided on October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 25, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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 $225 
copayment for Outpatient surgery. 
 
You have been asked to pay a $225 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 surgery 
provided on August 25, 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 enrollee exceeds the Medicare 
criteria for an LTACH appropriate admission and that an LTACH admission would be the most optimal 
opportunity for a successful outcome. The Plan denied your request. The Plan says the records show the 
enrollee's status is stable and improving and that the enrollee is receiving medically necessary acute and/or 
critical care. The Plan will continue to cover medically necessary acute and until the enrollee's condition is 
stable for transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical 
circumstances change such that LTACH services may be reconsidered. 
 
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 she 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation trips (A0100). You say that you 
are alone and do not have anyone that can take you. The Plan denied your request. The Plan says additional 
trips are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on August 31, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service and 
the amount you have already paid. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because oral hygiene instructions is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace described by code L1851. 
 
You asked the Plan to pre-approve the L1851 knee brace. You say that it is felt that this brace is required for 
the enrollee's condition. The Plan denied your request. The Plan says the LCD criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that the type of knee brace requested may be covered 
when the enrollee has one of the conditions listed in the LCD.  
 
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 L1851 knee brace. Our reviewer 
says that the coverage criteria for the requested brace are not met. Our physician reviewer found the enrollee 
has not had recent surgery or a recent injury. The documentation does not support that the joint is unstable, or 
that there is joint laxity. The requested knee orthosis 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 L1851 knee brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee brace described by code L1851.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is not enough medical information to show this is safe and helpful. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 enrollee's 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that you strongly recommend the 
injection to reduce the members pain and reduce the members need for oral pain requirements. You say that 
the member has ongoing pain that limits the member's ability to do activities of daily living. The Plan denied 
your request. The Plan says a sacroiliac joint injection 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 sacroiliac joint injection. Our 
reviewer says that the requested sacroiliac joint injection is not considered medically reasonable and necessary. 
Our physician reviewer found that the enrollee has not had physical therapy, therefore the enrollee has not had 
an adequate trial of conservative therapy. The request, at this time, is deemed not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.