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

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33350). 
 
You asked the Plan to pre-approve implanting a left atrial appendage closure (LAAC) device. You say that the 
enrollee has persistent atrial fibrillation with an increased risk of stroke having a CHADS2-V as c Score of 4. 
He has significant inflammatory arthritis and unable to gain relief with medication due to reactions with 
Eliquis. In addition, cost of Eliquis has been a concern for the enrollee. The Plan denied your request. The Plan 
says under Medicare guidelines, the request is not medically necessary because the enrollee's records show you 
have not participated in formal shared decision making with an independent non-interventional physician using 
an evidence-based decision tool on oral anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules say that LAACs are covered when all criteria provided in the 
Medicare Rules section of this letter 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 implanting a left atrial appendage 
closure (LAAC) device. Our reviewer says that the enrollee does not meet criteria for implant an LAAC device. 
Our physician reviewer found that at issue is the medical necessity of implanting a LAAC device in this 
enrollee in whom there is elevated risk of thromboembolic stroke due to atrial fibrillation and elevated 
CHADS2VASC score. There is no apparent contraindication to anticoagulation. As such, guidelines would not 
support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered 
reasonable or medically 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 implanting a left atrial appendage closure (LAAC) device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left 
atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), 
left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33350).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 recovering from a fall and you feel you 
would be more comfortable in a supervised setting. You say that you are immobile and are unable to perform 
daily activities. The Plan denied your request. The Plan says that the inpatient rehabilitation services you are 
requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you have a past medical history of multiple comorbidities who was hospitalized after a fall resulting in 
pelvic fracture and subdural hematoma. Clinical documentation states that you have multiple medical 
comorbidities that would benefit from close medical supervision on an inpatient basis. Evaluating therapists 
recommend intense rehabilitation and that you would tolerate the intense rehabilitation thus IRF criteria has 
been met and is medically reasonable and 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional aquatic therapy visits (97113). 
 
You asked the Plan to pre-approve aquatic therapy visits. You say that you have limited mobility. You say that 
you only went to 3 of the 12 previously approved visits due to a death in the family. You say that your visits 
have been extended 2 or 3 times already. You also say that you have been unable to make it work. The Plan 
denied your request. The Plan says the requested aquatic therapy visits are 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 aquatic therapy visits. Our reviewer 
says that the requested 9 aquatic therapy visits are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal physical exam deficits that require 9 
formal aquatic therapy visits. The reviewer found that you have back pain, but the documentation does not 
reveal that you are unable to perform land-based therapy. Therefore, the reviewer found that the request for 
additional aquatic therapy visits 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 aquatic therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 additional aquatic therapy visits (97113).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA services. You say that this procedure is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of 
radiofrequency ablation to the SI joint in the setting of chronic sacroiliac joint pain have not been demonstrated 
in the peer-reviewed literature. 
 
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 RFA services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for 
the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.  
Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI 
joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested SI joint RFA 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 RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve phentolamine (J2760). 
 
You asked the Plan to pre-approve phentolamine. You say that the enrollee needs this drug. The Plan denied 
your request. The Plan says the requested drug is not covered by Medicare for the enrollee's diagnosis. 
 
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 phentolamine. Our reviewer says that 
the requested drug, phentolamine, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug 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 in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested drug 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 phentolamine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve phentolamine (J2760).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 2, 2022 billed with 
codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 2, 2022 billed with codes 81194, 81301, 81455, and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for specific circumstances. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
shows this fracture is chronic not acute or subacute. Therefore, the request does not meet the criteria of the 
LCD. The request 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $120 copayment for emergency room services rendered on 
March 8, 2022. 
 
You asked the Plan to waive the $120 copayment for emergency room services. You say that you were not 
aware of having a copayment for an emergency room visit. The Plan denied your request. The Plan says you 
must pay a $120 copayment for emergency room services. 
 
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 $120 
copayment for Emergency Care.  
 
 
 
 
 
 
 You have been asked to pay a $120 copayment for emergency room services. Emergency room services fall 
within the Emergency Care 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 $120 copayment for 
emergency room services rendered on March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that this will help give doctors a better path for recovery. 
The Plan denied your request. The Plan says this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the 
records do not show that the enrollee is an appropriate candidate for an invasive diagnostic or therapeutic 
procedure regardless of the PET scan findings. The enrollee does not have an indication for which a PET scan 
can be covered at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion (22830) provided on October 26, 
2021. 
 
You asked the Plan to pay for exploration of spinal fusion (22830). You say that this was done to explore the 
fusion that was previously done at level L3-L4. You say that since nothing was done at this level you are 
allowed to charge for an exploration and payment for 22830 should be allowed. The Plan denied your request. 
The Plan says procedure code 22830 is considered inclusive to procedure code 63047. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22830 is exploration of spinal fusion. 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for exploration of spinal fusion (22830). Our reviewer says that 
the medical documentation does not support the use of procedure code 22830-51. Our reviewer found the 
provider took the enrollee to the operating room for the performance of procedure codes 63047 and 63048. 
While an exploration was performed, there was no additional surgical interventions nor was there a need for a 
change in the prior fusion surgery to bill procedure code 22830. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of exploration of spinal fusion (22830) have not been met. Therefore, we decided 
that the Plan does not have to pay for exploration of spinal fusion (22830) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing provided 
on October 13, 2021. 
 
You asked the Plan to pay for the urine PCR testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine polymerase chain reaction (PCR) testing provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 24, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given 
a choice for transportation and cannot afford the copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $265 
copayment after the deductible is met for each one-way ambulance trip.  
 
You have been asked to pay $177, which is less than the $265 copayment for the ambulance transportation. 
The ambulance transportation falls within the Ambulance 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 ambulance transportation provided on October 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on December 15, 
2021. 
 
You asked the Plan to pay for the infrared therapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says infrared therapy is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not medically necessary and is 
excluded from coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cortisone injection provided on August 
30, 2021. 
 
You asked the Plan to waive the copayment for a cortisone injection. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $250 
copayment for outpatient hospital services or ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for a cortisone injection. A cortisone injection falls within the 
Outpatient Hospital Services or Ambulatory Surgical Center 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 a cortisone injection provided on August 30, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you have upcoming dialysis 
appointments three times per week with your doctor and need additional trips for your transportation. The Plan 
denied your request. The Plan says that the requested trips exceed your routine transportation benefit. 
 
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. In this case file the Plan indicated they have not yet been able to obtain the trip 
report from the routine transportation vendor. Without this trip report showing covered transports we are 
unable to verify whether the enrollee has exceeded their maximum trips for 2022.  Therefore, we decided that 
the Plan has to pre-approve additional routine transportation.  
 
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.