Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitor supplies billed for date of service November 
4, 2021. 
 
You asked the Plan to pay for the glucose monitor supplies. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says the records do not support the date of service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, the proof of delivery you provided shows 
that the glucose supplies were shipped to the enrollee on November 3, 2021, and delivered on November 6, 
2021.  Nowhere on this proof of delivery is the date of service November 4, 2021, mentioned, and that is the 
date of service that you put on the claim.  The date of service should match the ship date, which is not the case here. Therefore, we decided that the Plan 
does not have to pay for glucose monitor supplies billed for date of service November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code(s) 33289 and 
C2624). 
 
You asked the Plan to pre-approve the device. You say that the services are necessary. The Plan denied your 
request. The Plan says the CardioMEMS device at this point should only be approved for patients enrolled in a 
clinical trial. 
 
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(s) 33289 and C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 20, 2022, by an 
out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the wound care supplies. You say that the wound care supplies are a separately 
billable expense that does not require separate authorization. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
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 did not pre-approve the 
wound care supplies. We found no exception that would require the Plan to pay for the wound care supplies. 
The records provided for review do not show that the wound care supplies were urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the wound care supplies provided on January 20, 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 an out-of-network referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are available within the plan's network of providers. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that you expect the enrollee to get better 
with LTACH care or that the enrollee will improve with a length of stay of about 25 days. 
 
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. The enrollee 
was admitted with unresponsiveness in the setting of intracranial hemorrhage. The record indicates that the 
enrollee still requires acute care services before transitioning to a lower level of care due to the severity of the 
neurologic deficit. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH services.  
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 for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI for the enrollee. 
 
You asked the Plan to pre-approve an MRI. You say that there is a possibility of a prostate needle biopsy based 
on the results of the magnetic resonance imaging. The Plan denied your request. The Plan says that that there 
are no plans for magnetic resonance/ultrasound (MR/US) fusion biopsy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that an MRI 
is medically reasonable and necessary. The records show that a prostate biopsy may be done, depending upon 
and utilizing the MRI findings. According to current AUA guidelines: In men who have been found to have an 
elevated PSA, after a shared decision-making process, if they elect to proceed with a prostate biopsy, there is 
now data to support that they should undergo an MRI prior to their initial biopsy. Our physician reviewer 
found that the enrollee's condition meets criteria for coverage of an MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan has to pre-
approve an MRI for the enrollee.  
 
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that she 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 8, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you rely on the facility to obtain 
information when they ask to see patients in their location. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a domiciliary or rest home visit was not filed until February 8, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 29, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided from January 29, 2022, to 
February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are 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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L5-S1, in this case, is 
not medically reasonable or 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2-S1 interbody fusion and posterior fusion for the 
enrollee. 
 
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documented instability, fracture, or lesion. Multilevel fusion for degenerative disc disease 
is not more effective than conservative measures in reducing back pain. 
 
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 L2-S1 interbody fusion and posterior fusion for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in your 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 ILR (CPT 
code 33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol HCL 50MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Tramadol is a self-administered drug and does not fall under Part B coverage. 
 
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 Tramadol HCL 50MG 
tablet.   
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 29, 2021. 
 You asked the Plan to pay for the testing services. You say that the test is reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is 
statutorily excluded. 
 
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. The records show that the gene panel at issue includes the FANCC 
gene. Panels of tests that include the FANCC gene are statutorily excluded. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient services on March 10, 2022. 
 
You asked the Plan to waive the copayment for Outpatient services. You say that you want to appeal the 
amount you are being charged. The Plan denied your request. The Plan says the cost-sharing you are being 
charged 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 $325 
copayment for each Medicare-covered non-surgical visit in an outpatient clinic. We cover medically-necessary 
services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. 
Covered services include, but are not limited to: Services in an emergency department or outpatient clinic, such 
as observation services or outpatient surgery. The provider billed in the allowed amount of $138.91. This is less 
than the copayment amount. Therefore, results in the total cost-sharing amount of $138.91.  
 
 
 You have been asked to pay a $138.91, which is less than the $325 copayment for Outpatient services. 
Outpatient services 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 copayment for Outpatient services on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine drug testing services provided on December 8, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says if 
documentation to support medical necessity is not submitted, the claim is denied. 
 The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
testing was ordered based on side effects, suspicious behaviors, or other clinician documented change in 
behavioral patterns. The file shows that the Plan made several attempts to obtain additional information with no 
success. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine drug testing services provided on 
December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage chair provided on March 13, 2022. 
 
You asked the Plan to pay for the massage chair. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says a massage chair is not covered by Medicare or 
under the Plan's supplemental benefit for reimbursement. 
 
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. Furthermore, a 
massage chair is not covered under the Plan's Pick Your Perks reimbursement program. Therefore, we decided 
that the Plan does not have to pay for the massage chair provided on March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 outpatient hospital services provided on March 4, 
2022, by an out-of-network (OON) provider.