Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a cardiac contractility modulation (CCM) 
device. 
 
You asked the Plan to pre-approve the CCM placement. You say that this device will be beneficial for the 
enrollee's condition. The Plan denied your request. The Plan says this device has not been shown to definitely 
improve outcomes for people with CHF. 
 
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 CCM placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male with left ventricular dysfunction and continued symptoms 
despite medical treatment. His symptoms are thought to reflect congestive heart failure (CHF). At issue is 
whether implantation of the CCM system in this patient is medically necessary for the treatment of CHF which 
has been deemed refractory to optimal medical therapy. An exhaustive review of the current medical literature 
pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis 
pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores 
and objective functional capacity.  
 
While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, the CCM system is not considered to be medically 
necessary in this patient. 
 
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 CCM placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a cardiac contractility modulation (CCM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis, plastic or other material with ankle joint, 
prefabricated, includes fitting and adjustment (L1971) foot, plastic, silicone or equal, heel stabilizer, 
prefabricated, off-the-shelf (L3170) provided September 3, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment (L1971) foot, 
plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf (L3170) provided September 3, 2021.
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 would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of the requested IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program.  There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service October 29, 
2021. 
 You asked the Plan to pay for procedure code 74018. You say that the medical records support payment for this 
code. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for code 
74340. 
 
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 74018 
is a column II code to column I code 74340. 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 74018 billed for date of service October 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5253) purchased on July 7, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you should be reimbursed for this hearing aid, 
which was necessary and cost less than your benefit allowance. The Plan denied your request. The Plan says 
you previously purchased a hearing aid on July 1, 2019, which used your full $1,000 allowance. Your hearing 
benefit provides a $1,000 allowance toward the cost of hearing aids once every three years. It has been less 
than three years since your last hearing aid purchase; therefore, this service is denied as the frequency 
limitation of your benefit has been exceeded. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids up to $1,000 once every three years.  
 
We looked at the file and the Plan's rules. Documentation shows that you previously used your hearing aid 
benefit less than three years before the date in question.  
 
 
 
 
 Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aid (V5253) purchased on July 7, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on November 19, 2021. 
 
You asked the Plan to pay for the service provided. You say that the code is not inclusive with any other 
service. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
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 88341 is immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure) 
 
 We looked at the file and the rules. We find that CPT code 88341 was not billed with a primary procedure. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab service provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because 
the requested procedure is medically necessary. The Plan denied your request. The Plan says this device is 
experimental. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety 
and efficacy. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Interspinous Spacer device.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee's needs are being met in the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 pay for the periapical x=ray (D0220), recement or rebond of crown 
(D2920), and scaling and root planing (D4341) provided on October 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have gum disease. You say that this is a 
medical condition. You say that this should be covered by Medicare and your plan. You also say it is your 
understanding that your plan pays for dental treatments. The Plan denied your request. The Plan says the 
services you received are not listed as covered dental services. 
 
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, it is limited to preventive dental 
services. The periapical x-ray, recement or rebond of crown, and scaling and root planing that you received are 
not considered preventive and are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the periapical x=ray (D0220), recement or rebond of crown (D2920), and scaling 
and root planing (D4341) provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing services provided on October 4, 
2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services do not 
meet coverage criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The definitive drug testing at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the definitive drug testing services provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81404, 81405, 81406) provided on August 5, 
202. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 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 codes 
81404, 81405, and 81406, are column II codes to column I code 81432. 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 the services (81404, 81405, 81406) provided 
on August 5, 202.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on June 
15, 2021 to June 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that the enrollee was custodial at the time and you are 
billing for outpatient therapies. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 the skilled nursing facility (SNF) services 
provided on June 15, 2021 to June 30, 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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician office visits on October 25 to November 22, 2021. 
 
You asked the Plan to pay for physician office visits. You say that you were not aware reimbursement was not 
an option for the provider at issue or you would have selected a different provider. The Plan denied your 
request. The Plan says rules for payment have not been met because the provider at issue has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
office visits on October 25 to November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Insulin Aspart Flexpen. 
 
You asked the Plan to pre-approve the Flexpen. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Insulin Aspart Flexpen.  
 
Benefits for the Flexpen may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full purchase of an ultra-lightweight manual 
wheelchair. 
 
You asked the Plan to pre-approve the full purchase of the requested wheelchair. You say that you will be 
having surgery and will need the wheelchair after the surgery. The Plan denied your request. The Plan says 
durable medical equipment cannot be approved prior to showing an actual need. The Plan also states the in -
home assessment shows you do not need a wheelchair for full time use. You are expected to return to full 
functional gait following your surgery. The Plan states that due to the nature of the surgery, you may be eligible 
for a rental depending on surgical precautions and sitting tolerance once the surgery is completed but not 
purchase.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. At the time of the appeal, you did not use a wheelchair full time and this purchase 
request was in anticipation of need, which is not covered. The Plan notes they would approve the rental of a 
wheelchair for a period of time if your condition after the surgery showed it was necessary. Therefore, we 
decided that the Plan does not have to pre-approve the full purchase of an ultra-lightweight manual wheelchair.