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

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve skilled nursing facility  SNF care. You say that the enrollee's continued 
inpatient rehab stay at a SNF is medically necessary. The Plan denied your request. The Plan says SNF 
admission is not medically necessary. The enrollee care can be met in an assisted living facility with home 
health services. The enrollee may also receive services they need at a long-term care setting with part-time 
skilled services. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily 
basis. The enrollee is medically stable without any acute exacerbations of chronic medical problems and can 
receive further rehab services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0239U) billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that you have provided records to support the services 
billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Specifically, the case record documents that the specimen was 
not collected on the date of service billed. We found no grounds for an exception to the rule. Therefore, we 
decided that the Plan does not have to pay for genetic testing (0239U) billed for date of service January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin treatment called Kerecis omega3, per square 
centimeter (Q4158). 
 
You asked the Plan to pre-approve Kerecis omega3 skin substitute. You say that due to the wound size and 
location, you are requesting authorization for the use of Kerecis Omage3 skin substitute to assist and promote 
proper wound healing for the enrollee. The Plan denied your request. The Plan says the request does not meet 
the Medicare or health plan coverage criteria. 
 
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 Kerecis omega3 skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the case file does not contain documentation that the wound has failed to 
respond to documented appropriate wound-care measures, has increased in size or depth, or has not changed in 
baseline size or depth. There is no indication that improvement is likely (such as granulation, epithelialization 
or progress towards closing), is clean and free of necrotic debris or exudate, and has adequate 
circulation/oxygenation to support tissue growth/wound healing as evidenced by physical examination (e.g., 
Ankle-Brachial Index of no less than 0.60, toe pressure greater than 30 mmHg). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis omega3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a skin treatment called Kerecis omega3, per square centimeter (Q4158).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on August 1, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a ballet class purchased on January 1, 2022. 
 
You asked the Plan to reimburse you for a ballet class. You say that this should be covered under your wellness 
allowance. The Plan denied your request. The Plan says ballet classes are not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits have not been met because ballet classes are not a covered 
benefit. Therefore, we decided that the Plan does not have to reimburse you for a ballet class purchased on 
January 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 3, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the service should 
be covered. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation 
benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies rendered on May 6, 2022. 
 
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 code A4223 is for infusion supplies not 
used with a covered external infusion pump. 
 
We looked at the file and Medicare rules. Billed procedure code A4223 is for infusion supplies used with a 
non-covered infusion pump. These services are not covered by Medicare. Therefore, we decided that the Plan 
does not have to pay for the infusion supplies rendered on May 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered 
from April 7, 2022, to April 11, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment. 
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 $375 
copayment each day for days 1-5 for in-network inpatient hospital care.  
 
Review of the file shows that you received three days of inpatient hospital care from April 7, 2022, to April 11, 
222. You have been asked to pay a $375 copayment each day for these services, for a total of $1,125. This 
item/service falls within the in-network inpatient hospital care 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 inpatient hospital services rendered from April 7, 2022, to April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We reviewed the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the medical records provided in this case do not 
indicate that you have a diagnosis of a subluxation of the spine. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatment (98940).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomographic angiography (CTA), of the heart with 
contrast (75574). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that a similar study to the one requested has 
been previously approved. However, the Plan has not stated which study was approved nor have they provided 
medical records to substantiate their denial. Therefore, we decided that the Plan has to pre-approve computed 
tomographic angiography (CTA), of the heart with contrast (75574).  
 
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: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee is not in the position to undergo surgery 
at this time. You also say that they would like to maximize conservative options. The Plan denied your request. 
The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are covered when the pain duration of at least 
four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure 
to respond to four (4) weeks of noninvasive conservative care. 
 
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 ESI. Our reviewer says that the 
requested ESI is medically necessary. Our physician reviewer found the provided documentation indicates that 
the enrollee has tried chiropractic care and a home exercise program (HEP). The reviewer found that these 
conservative therapies did not provide sustained pain relief. Therefore, the reviewer found that the requested 
injection is medically necessary in this case. 
 
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 ESI have not been met. Therefore, we decided that the Plan has to pre-
approve epidural steroid injection (ESI) (64483).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that it is detrimental to the enrollee's health and well-being 
for this implant. The Plan denied your request. The Plan says this procedure does not meet criteria because 
there is no documentation of syncope or cryptogenic stroke. 
 
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 ILR. Our physician reviewer found 
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 the ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop reader (ILR) (CPT code 33285).
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 the enrollee was previously completely 
independently and now requiring PT and OT at high intensity to return to normal. The Plan denied your 
request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not been 
met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of 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 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 Intensity Modulated Radiation Treatment (IMRT) 
(77386). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee needs radiation therapy, and the treatment 
has changed from palliative to definitive treatment. Waiting for 30 days may jeopardize his health. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records do not offer an explanation as to why, or offer a quantifiable rationale, for 
why IMRT is needed in the enrollee. No specific information about a 3D conformal plan being unacceptable 
was provided. In summary, IMRT is not experimental, but rather a useful tool available to radiation oncologists 
to potentially reduce toxicity and improve the dose distribution in patients when the dose-volume exposure of 
normal tissues warrants its use. ASTROs position is that IMRT is necessary when the need is sufficiently 
supported. Without plausible justification for the need of IMRT (over standard 3D conformal radiotherapy), the 
LCD criteria is not met as IMRT would not be furnished in accordance with accepted standards of practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Treatment (IMRT) (77386).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021, billed with 
codes 81439, 81286, 81410, 81411, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare guidelines, and this testing is not covered when it is provided as a screening. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 23, 2021, billed with codes 81439, 81286, 81410, 81411, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service January 1, 
2022. 
 
You asked the Plan to pay for procedure code 99051. The Plan denied your request. The Plan says procedure 
code 99051 is considered bundled and 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 procedure code. 
 
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service January 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carfilzomib (Kyprolis) (J9047).  
You asked the Plan to pre-approve carfilzomib. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says routine costs associated with this clinical trial are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve carfilzomib as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve carfilzomib (Kyprolis) (J9047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reaching/grabbing device (A9281). 
 
You asked the Plan to pre-approve a reaching/grabbing device. You say that you had back surgery and your 
provider advised not to reach. The Plan denied your request. The Plan says this is not a covered item with 
Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reaching/grabbing device (A9281).