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

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device was 
approved by the Food and Drug Administration (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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH setting is the most 
appropriate setting to continue the enrollee's treatment. The Plan denied your request. The Plan says the 
Medicare guidelines were not met, and the enrollee is receiving the care they need in the hospital where they 
are at. 
 
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 short-term acute care hospital can provide for all of the enrollee's present 
inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The 
provided records do not explain what care services will be provided in the LTACH that are not available in the 
present hospital setting. The health plan has not stated that continued care in the short-term acute care hospital 
will not be covered. 
 The enrollee is presently receiving appropriate services in the short-term acute care setting. Continued care in 
the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care 
such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
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 the LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you thought the service would be 
covered and you cant afford the copayment for the colonoscopy 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 $290 
copayment for colorectal cancer screening. 
 
You have been asked to pay a $290 copayment for a colonoscopy. This item/service falls within the colorectal 
cancer screening 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 colonoscopy 
provided on June 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service March 23, 
2022, to April 21, 2022. 
 You asked the Plan to pay for home health services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says you have not submitted an NOA. 
 
The Plan must follow Medicare rules. Medicare rules say that, for each admission to home health, the HHA 
notifies Medicare systems via submission of an NOA. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record does not support that an 
NOA was submitted pertinent to the period of care at issue. Therefore, we decided that the Plan does not have 
to pay for home health services billed for dates of service March 23, 2022, to April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298), miscellaneous hearing services 
(V5299), and a hearing aid dispensing fee (V5090) provided on February 9, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298), miscellaneous hearing services (V5299), and a hearing 
aid dispensing fee (V5090). You say that only when you were preparing your materials to apply for 
reimbursement did you come across the annual notice of changes from 2021, which addressed a new system of 
designated providers for the hearing devices. You also say you had partly missed it because you were not 
dealing with the possibility of new devices during that year. The Plan denied your request. The Plan says the 
hearing benefit is not covered if the services are not registered in advance. The Plan also says that 
miscellaneous hearing service (V5299) is not a covered benefit. 
 
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 only when they are purchased through the Plan and the Plan is contacted first.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298), miscellaneous hearing services (V5299), and a hearing aid dispensing fee 
(V5090) have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid 
(V5298), miscellaneous hearing services (V5299), and a hearing aid dispensing fee (V5090) provided on 
February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that want to go to rehabilitation to get back to being 
mobile and not SNF as your family feels that it will not provide enough care. The Plan denied your request. 
The Plan says your needs can be met at a lower level of care such as skilled nursing facility (SNF), home health 
or 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 are no complex nursing or rehabilitation needs. While you have a need for 
physical 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture (97814). 
 
You asked the Plan to pre-approve acupuncture. You say that you need acupuncture for back pain, arthritis, and 
headaches. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file does not support a diagnosis of chronic low 
back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture (97814).
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 you would benefit from long term acute 
care services due to your medical complexity. The Plan denied your request. The Plan says they will continue 
to cover medically necessary acute and critical care at the current facility until your condition is stable for 
transfer to an alternate level of care (such as a skill nursing facility), or until the clinical circumstances change 
such that LTACH 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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 4, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the timely filing 
denial to be waived, and the claim to be reprocessed with payment for medical services provided in good faith. 
The Plan denied your request. The Plan says this claim was denied correctly for untimely filing as the claim 
was filed past the filing limit of 365 days. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital services was not filed until June 10, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital services provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma provided on June 2, 2022. 
 
You asked the Plan to pay for platelet rich plasma. You say that platelet rich plasma was medically necessary. 
The Plan denied your request. The Plan says platelet rich plasma is considered experimental and investigational 
because its effectiveness for osteoarthritis (OA) has not been established. 
 
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 platelet rich plasma provided on 
June 2, 2022 have been met. Specifically, medical records were not provided to determine that Medicare 
coverage have been met. Therefore, we decided that the Plan does not have to pay for platelet rich plasma 
provided on June 2, 2022.
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 enrollee may benefit from physical therapy 
treatment to achieve the enrollee's goal to walk with no pain. The Plan denied your request. The Plan says the 
requested IRF services 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that knee arthroplasty is routinely managed at an outpatient level. There is no evidence-based support indicating intensive rehabilitation is medically necessary. The enrollee does not require 
frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that placement of an ILR is only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of an ILR. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a history of atrial fibrillation. While the enrollee has a history of 
atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this 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 placement of a ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic with electronic knee features (L5828, 
L5845, L5848, L5850, L5856, L5925). 
 
You asked the Plan to pre-approve a prosthetic with electronic knee features. You say that you desperately 
need your advanced knee that was recommended to you to live independently. The Plan denied your request. 
The Plan says the request for microprocessor knee does not meet Medicare criteria of reasonable and 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 prosthetic with electronic knee 
features. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for acquired absence of left 
leg above the knee. The enrollee presented to the provider noting the need for replacement socket with a 
microprocessor-controlled knee and K3 level foot. The treatment plan included that the enrollee is in need of a 
new replacement socket. The current socket is no longer fitting due to loss in volume. However, despite the 
provider noting that the enrollee has increased the functional level from a K2 to K3, the provider failed to 
document why this enrollee is in need of the requested microprocessor-controlled knee over a K3 mechanical 
knee.  Per the LCD, Coverage is extended only if there is sufficient clinical documentation of functional need 
for the technologic or design feature of a given type of knee. This criterion has not been met. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines.  
 
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 prosthetic with electronic knee features have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a prosthetic with electronic knee features (L5828, L5845, 
L5848, L5850, L5856, L5925).
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 meets LTACH admission 
criteria. The Plan denied your request. The Plan says the Medicare guidelines for LTACH admission were not 
met and the enrollee can safely receive the care that they need in their current acute care 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 that 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 they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 30, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON laboratory services. You say that the records provided support the 
services in dispute. The Plan denied your request. The Plan says the services in dispute are non-covered 
because of the provider's network status. 
 
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 laboratory services provided on January 30, 2020, 
by an out-of-network (OON) provider.