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

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Current Procedural Terminology 
(CPT) code 64628) and thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; each additional vertebral body, lumbar or sacral (CPT code 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because there is little evidence in 
the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain, especially 
given their disc bulge, spinal stenosis, and facet arthrosis. The Plan states the requested procedure is not an 
accepted standard of medical practice for the diagnosis or treatment of back pain and it is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure remains experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (Current Procedural Terminology (CPT) code 64628) and thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (CPT code 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound provided on 
October 7, 2021. 
 
You asked the Plan to waive the copayment for ophthalmic ultrasound. You say that you have always had a 
$30 copayment for your appointment and x-rays. You say that you were never billed for an additional amount 
but are now being billed an extra charge. The Plan denied your request. The Plan says copayment is 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 $30 
copayment for other Medicare-covered outpatient diagnostic test from a specialty physician.  You have been asked to pay $11.41, which is less than the standard $30 copayment for an ultrasound. The 
ophthalmic ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies 
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 the ophthalmic ultrasound 
provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on January 7, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct 
POS code. 
 
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 Tempus Gene Panel 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 Tempus Gene Panel provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a night guard (D5999). 
 
You asked the Plan to pre-approve the dental item. You say that this appliance has been shown both through 
research and clinical application to greatly improve the deleterious effects experienced during obstructed sleep 
disorder. You also say that the benefits include having a positive effect on the enrollee's overall health and 
sleep. The Plan denied your request. The Plan says a night guard is not medically necessary. 
 
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 night guard is not among 
those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve involve the 
care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. 
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does 
not have to pre-approve a night guard (D5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve for the enrollee. 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that this will help reduce the enrollee's 
swelling. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is denied as noncovered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to pre-
approve a mastectomy sleeve for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered 
 
 The Plan must follow Medicare rules. The rules say that products currently classified as HCPCS code E0465, 
E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless 
of the underlying medical condition, shall not be paid in the FSS payment category. 
 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual language to indicate that these services are included in the dialysis rate. The Plan denied 
your request. The Plan says payment for these services is bundled into the dialysis rate. 
 
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 laboratory services provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test, a combinatorial pharmacogenic 
test (81479) provided September 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the GeneSight test was denied on the basis 
that the procedure code is purportedly invalid, which you believe to be erroneous. The Plan denied your request. The Plan says GeneSight psychotropic has not been show to be useful, is not considered medically 
necessary and appropriate and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for GeneSight psychotropic test, a combinatorial pharmacogenic test (81479) provided September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pimecrolimus cream 1%. 
 
You asked the Plan to pre-approve the cream. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a self-administered drug. 
 
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 Pimecrolimus cream 1%.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the services. You say that the enrollee urgently needs this device and 
procedure due to their worsening heart failure. The Plan denied your request. The Plan says there is no 
indication that this enrollee is enrolled in a clinical trial of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 congestive heart failure (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 (1). Subsequent follow-up studies remain encouraging and suggest an improvement 
in heart failure symptoms with the use of the device (2). 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMS HF System (CPT code(s): 33289 and C2624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that you would like the enrollee to be treated with Ilumya 
to better manage her psoriasis and get her skin clear. The Plan denied your request. The Plan says this request 
does not meet the Plan's Part B step therapy criteria for Ilumya. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the patient has not 
tried and failed the required drug, Stelara. Our reviewer also found that there is no indication that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a 
network provider on November 29, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be 
responsible for the copayment because you were not evaluated. The Plan denied your request. The Plan says 
you have been asked to pay 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 $30 
copayment per visit for specialists (in-office/telehealth). For this date of service, you have been asked to pay 
the allowed amount of the claim because this amount is less than the standard $30 copayment for the specialist 
office visit. 
 
You have been asked to pay a $22.61 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office visits benefit category. The medical 
record shows telehealth services were rendered. 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 the 
specialist office visit provided by a network provider on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that when this procedure started, you were told the crown was covered at 50% to 75% 
regardless of where it was placed. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits (97810, 97811, 97813). 
 
You asked the Plan to pre-approve additional acupuncture visits. You say that you have postherpetic neuralgia 
on the side of your neck. The Plan denied your request. The Plan says you have used the acupuncture benefit to 
obtain your services which was a supplemental benefit from the plan. The Plan also says you do not qualify for 
acupuncture services as covered by Medicare as you do not have chronic back pain as your pain is not 
musculoskeletal in nature but due to post-herpetic neuralgia and is not on your back. 
 
 
 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. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
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 Plan approved 12 sessions, which is the 
maximum covered number of visits for the initial 90-day period. The EOC confirms that acupuncture is 
covered for chronic low back pain. The records show you do not have chronic back pain.  Therefore, we 
decided that the Plan does not have to pre-approve additional acupuncture visits (97810, 97811, 97813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart device; automatic external defibrillator, with 
integrated electrocardiogram analysis, garment 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 this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient had an echocardiogram in 8/2021 showing an ejection fraction of 25%, with no significant 
ventricular tachyarrhythmias documented. He was treated with medication and a defibrillator was implanted on 
January 2022. The wearable defibrillator is a vest-like device worn under the clothing that continuously 
monitors the heart rhythm and automatically delivers an electric shock when ventricular fibrillation (VF) and 
pulseless ventricular tachycardia (VT) is detected. This device is intended to be worn continuously, 24 hours 
per day, except when the wearer is bathing or showering. As such, it would not appear that the patient was a 
candidate for a wearable defibrillator according to current 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a heart device; automatic external defibrillator, with integrated electrocardiogram analysis, 
garment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves rendered on October 28, 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 must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded. 
 
We looked at the file and Medicare rules. Billed procedure code A4930 (sterile gloves, per pair) has a status 
indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not 
have to pay for the sterile gloves rendered on October 28, 2021.