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

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on November 3, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 37184. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services rendered on November 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the 
member required skilled rehab services to improve function due to weakness and deconditioning. There were 
no skilled nursing needs. As of May 25, 2022, the member did not require any skilled nursing or rehab services 
on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member 
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the 
member did not require any skilled services on an inpatient basis, at a SNF level of care as of May 25, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 3 home health skilled nursing visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 3 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not 
require additional skilled nursing services to effectively provide treatment, care, and/or services in order to 
improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are 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 3 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have been seeing this dentist for 9 
years. You say that you do not want to change dentists now. You say that you have anxiety when getting dental 
work done. You also say that you are comfortable with this provider. The Plan denied your request. The Plan 
says the requested provider is out of network. The Plan also says that dental services are covered with providers 
in the Dental Plan's preferred provider organization (PPO) network only. 
 
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 provider is not in the 
Dental Plan's PPO network. Services you receive from this provider are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an 
out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative neuromonitoring (95939, 95861, 95938, 
95937). 
 
You asked the Plan to pre-approve the intraoperative neuromonitoring. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the intraoperative neuromonitoring. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found during this type of procedure the area of most importance is the brain. The 
services/modalities requested are not of general utility in this type of surgery as they are not specific for any 
potential intraoperative changes. 
 
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 intraoperative neuromonitoring have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intraoperative neuromonitoring (95939, 95861, 95938, 95937).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 Baroreflex stimulation devices have been considered potential alternative treatments for resistant 
hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath 
the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019, the Food and Drug Administration (FDA) approved the system for use in patients with refractory 
heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are New 
York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, 
distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an absence of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim 
Neo in patient management. As a result, at this time the Barostim Neo system would not be considered 
medically reasonable and 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 Barostim Neo device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the knees. The record does not demonstrate that the enrollee has 
failed conservative nonpharmacologic therapy. The Food and Drug Administration 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. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Smartview diabetic test strips. 
 
You asked the Plan to pre-approve Accu-Chek Smartview diabetic test strips. You say that the requested items 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested brand of diabetic supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Accu-Chek Smartview diabetic test strips have not been met. Specifically, the requested item is a 
non-preferred brand. The case record does not contain medical documentation that supports the medical 
necessity of the specific requested item. Therefore, we decided that the Plan does not have to pre-approve 
Accu-Chek Smartview diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6250 that 
were issued on February 18, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6250 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6250 that were issued on February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve Xifaxan tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Xifaxan tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Xifaxan tablets.  
 
Benefits for Xifaxan tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee has end-stage renal disease. The Plan denied your request. The Plan says a network provider can care for the enrollee's medical problem.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services provided to the enrollee on December 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the coding criteria 
is not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the plan provided 
notice that the services would not be covered. Under Medicare rules, this means the services is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the services provided to the enrollee 
on December 6, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 home health physical therapy visits. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you are walking 250 feet independently 
with no assistive device and need assistance with transfers and activities of daily living. The records do not 
support that you require the skills of a professional therapist to effectively provide treatment, care, and/or 
services in order to improve you level of function, or to establish/perform a maintenance program to maintain 
your level of function and/or prevent deterioration. The additional services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 14 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on December 23, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99222 is not separately payable. 
 
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 99222 
is a column II code to column I code 99223. 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 initial hospital care rendered on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for 20 extractions (D7140), 8 implants (D6010), bone 
replacement graft (D7953), immediate dentures (D5130, D5140), and sedation services (D9243) provided on 
December 10, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that your insurance coverage for 2021 
clearly states that you will be reimbursed up to $500 for preventive dental services and $500 for comprehensive 
dental services. You say that the services were not medical. You also say that you should be reimburse for the 
allowable amount. The Plan denied your request. The Plan says the services were denied correctly. 
 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, dental services received by a non-
Medicare provider are not among those covered under this benefit. The record shows that you received these 
services outside of the United States and therefore the provider would not be eligible for Medicare coverage. 
Therefore, we decided that the Plan does not have to reimburse you for 20 extractions (D7140), 8 implants 
(D6010), bone replacement graft (D7953), immediate dentures (D5130, D5140), and sedation services (D9243) 
provided on December 10, 2021.