Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74176). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that it is medically necessary 
for the enrollee to have a CT scan of the abdomen and pelvis for management of a kidney stone. The Plan 
denied your request. The Plan says that there is no medical necessity for an additional scan at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee has multiple right sided stones. Our reviewer also found that this request 
for a CT of the abdomen and pelvis is reasonable in order to determine if the stent needs to stay in place due to 
intra-ureteral stones. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).  
 
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: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee's ongoing care needs can be provided at a lower level. 
 
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 was admitted for COVID and rhabdomyolysis after a fall. 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 medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgery procedure provided on April 20, 
2022. 
 
You asked the Plan to waive the coinsurance for surgery procedure. You say that you are disputing the charges. 
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 50% 
coinsurance for Outpatient hospital services. The allowed amount of this surgery procedure total $773.65, 
resulting in a coinsurance amount of $386.82. 
 
You have been asked to pay 50% coinsurance for surgery procedure. This item/service falls within the 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for surgery 
procedure provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
June 22, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you should not have a 
copayment for telehealth visits. 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 $45 
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist. The Plan 
contract also says that you pay the cost-sharing that applies to primary care services or specialist physician 
services for Medicare-covered telehealth services received from your PCP or a specialist, respectively. You have been asked to pay $45 for a specialist telehealth visit. This item/service falls within the telehealth 
visit 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 specialist telehealth visit 
provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on April 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injections. You say that in good faith the provider believed the administrative 
requirements for the claim had been met prior to rendering service. You also say the provider disagrees with 
this determination and is appealing. The Plan denied your request. The Plan says the enrollee must receive care 
from a network provider. 
 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 injections provided on April 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve real wave ultrasound therapy. 
 
You asked the Plan to pre-approve real wave ultrasound therapy. You say that the requested service is 
medically necessary in the treatment of the enrollee's condition. The Plan denied your request. The Plan says 
the requested service is not being performed in conjunction with physical, occupational, or speech therapy. 
 
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 real wave ultrasound therapy. Our 
reviewer says that the requested real wave ultrasound therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation does not indicate a loss of 
function that needs skilled treatment. The reviewer found that the requested treatment is for pain only. 
Therefore, the reviewer found that the requested service is 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 real wave ultrasound therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve real wave ultrasound therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you cannot continue to pinch yourself 
because you are tired and old. The Plan denied your request. The Plan says you do not meet coverage criteria 
for approval of the requested CGM and supplies. 
 
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 you use insulin with at least three 
daily injections or 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 and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
and supplies (K0553, K0554).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an air ambulance provided on January 22, 
2022. 
 
You asked the Plan to waive the coinsurance for an air ambulance. You say that there was no other way to 
make it the hospital. 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 20% 
coinsurance for out of network ambulance services.  
 
You have been asked to pay a 20% coinsurance for an air ambulance. The allowed amount for the ambulance 
services is $7,696.76. The amount you are being asked to pay is $1,539.35 ($7,696.76 x 20% = $1,539.35). 
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 coinsurance for an air ambulance provided on January 22, 2022.
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 a lower level of care cannot meet the 
enrollee's needs. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and does not require transfer to an LTACH. 
 
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 appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS high frequency system. 
 
You asked the Plan to pre-approve CardioMEMS high frequency system. 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 high frequency system. 
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 high frequency system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CardioMEMS high frequency system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your provider ordered a 
portable oxygen concentrator for you because you cannot leave your home for any length of time. If you had 
the oxygen concentrator, you would be able to live a much better life and have freedom to leave the area and 
travel to visit family and friends. The Plan denied your request. The Plan says a portable oxygen concentrator 
cannot be preauthorized for you. There is no indication your current oxygen equipment is not meeting your 
medical needs or ADLs in or around the home. You have not been evaluated by respiratory therapy for a 
portable oxygen concentrator. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the POC is considered not medically necessary because Medicare criteria 
are not met.  The medical records do not show that you are able to maintain SpO2 of greater than 91% during 
activity while on oxygen 1 to 4 L/min using an oxygen conserving device. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the services needed could be provided in another setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 he is 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that an epidural steroid injection does not 
meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is medically necessary. Our physician reviewer found that the 
enrollee is a 36-year-old woman with chronic low back pain with radiation to her right leg with a diagnosis of 
lumbar radiculopathy. She takes Tizanidine, Gabapentin and Fluoxetine for pain. She has tried physical therapy 
in the past and also has a TENS unit. She had a spinal cord stimulator in the past for a different reason and it 
was explanted. The enrollee meets all of the criteria for an epidural steroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an x-ray examination of the ankle, and an x-
ray examination of the foot provided on June 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, an x-ray examination of the ankle, and an x-ray examination of 
the foot. You say that the services were rendered in good faith and were medically necessary. The Plan denied 
your request. The Plan says services from non-participating providers are not covered under your plan unless 
they are authorized by the Plan before the services are provided. 
 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 an office visit, an x-ray examination of the ankle, 
and an x-ray examination of the foot provided on June 20, 2022, by an out-of-network (OON) provider.