Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility will not provide 
adequate physician, nursing and therapy coverage for the enrollees current health disposition. The Plan denied 
your request. The Plan says the request 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse exercise classes with a non-physician provider (S9451) 
provided from  April 1, 2022, to May 27, 2022. 
 
You asked the Plan to reimburse exercise classes with a non-physician provider (S9451). You say that with the 
pandemic world, your senior center is very safe (temperature check, vaccine required). You also say you chose 
this place to get the exercise you need to keep your bones strong. The Plan denied your request. The Plan says 
the service obtained was rendered by a provider who is not under contract with the Plan and is not certified 
with Medicare. 
 
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 Plan covers gym benefits 
only when the provider has not opted out of or been excluded/precluded from the Medicare program. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the provider is not certified or 
participating in Medicare. Therefore, we decided that the Plan does not have to reimburse exercise classes with 
a non-physician provider (S9451) provided from  April 1, 2022, to May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided on May 11, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy provided on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure with stenting. 
 
You asked the Plan to pre-approve revascularization procedure. You say that this procedure is necessary for the 
enrollee's health and well-being. 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 revascularization procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a current smoker who on last formal assessment complained 
of no claudication and was referred for chest pain. There is no documentation of rest pain or tissue loss. There 
is no documentation as to the nature of the enrollee's pain, whether the pain is lifestyle limiting, whether the 
enrollee was appraised of the risks and benefits and even wants the procedure, and no documentation of any 
concerted effort to treat conservatively. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a revascularization procedure with stenting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an 
elective right elective total shoulder arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care to be provided after 
an elective right elective total shoulder arthroplasty is medically necessary. The Plan denied your request. The 
Plan says the elective procedure is not on the CMS inpatient only list. The preoperative clearance and comorbid 
conditions suggest that the procedure could initially be performed on an ambulatory/observation basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the documentation indicates that the 77-year-old enrollee with shoulder 
pain with prior rotator cuff repair and arthropathy is undergoing a planned reverse total shoulder arthroplasty. 
The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. 
The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. There is no documentation provided to support 
the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the 
record does not show that the admitting physician reasonably expects that the enrollees necessary hospital care 
will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective right elective 
total shoulder arthroplasty.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient readmission provided from January 13, 2022, to January 
18, 2022. 
 
You asked the Plan to pay for the inpatient readmission. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says that the enrollee was discharged prematurely which 
directly led to their readmission in the same institution. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 pay for the inpatient readmission. Our reviewer says 
that the inpatient readmission was medically reasonable and necessary. Our physician reviewer found the 
documentation indicates that the enrollee was stable and appropriate for hospital discharge on January 10, 
2022. Our reviewer also found that for the period of January 13, 2022, to January 18, 2022, a readmission was 
medically necessary and was not the result from a premature discharge from the same hospital.  
 
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 inpatient readmission have been met. Therefore, we decided that the Plan 
has to pay for the inpatient readmission provided from January 13, 2022, to January 18, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (GAE) for the knee. 
 
You asked the Plan to pre-approve GAE for the knee. You say that the requested procedure is medically 
necessary. You say that the enrollee's prior treatments included conservative therapy with non-steroid anti-
inflammatory medications and steroid injections, both of which failed. You say that the enrollee is attempting 
to delay a major surgery for 4 or 5 years. The Plan denied your request. The Plan says the procedure is 
considered investigational and will require additional safety and efficacy data to confirm its role in the 
management algorithm for knee osteoarthritis. 
 
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 GAE for the knee. Our reviewer says 
that GAE for the knee is not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding severe osteoarthritis in the left knee (with 
failure of recent conservative measures). The October 5, 2022, x-rays of the left knee have an impression of 
moderate osteoarthritis. The injections for the knee were not noted to be recent, and there is no clear 
documentation of failure of any recent physical therapy for the knee. There are limited large-scale, long-term references showing the safety and efficacy of the requested procedure in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GAE for the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular artery embolization (GAE) for the knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this service was billed with an appropriate 
place of service. The Plan denied your request. The Plan says that this service is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that no payment is recognized for CPT code 85060 furnished to hospital outpatients or non-hospital 
patients. When an independent laboratory bills a physician interpretation of an abnormal peripheral blood 
smear, the service is considered a complete or global service, and is not billed under the CPT code 85060. 
 
The records indicate that this service was provided to an enrollee who was in an outpatient hospital setting at 
the time of services (as indicated by Place of Service code 22) and was billed by an independent laboratory. 
Based on this information, we decided that Medicare rules for coverage of procedure code 85060 have not been 
met as this is an inappropriate code for this provider to use. Therefore, we decided that the Plan does not have 
to pay for procedure code 85060 billed for date of service May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the device prevents further heart failure 
hospitalizations. The Plan denied your request. The Plan says the clinical value has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as home with home health, in residential care, or home with close follow-up with 
their doctor. 
 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 the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services are not shown to have been required to establish 
a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test(s) 22 or more drug class(es), including 
metabolite(s) if performed (CPT code G0483) provided on February 7, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not support 22 or more drug classes, only 21 drug classes were 
tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the documentation does not support 22 or more drug classes, only 21 drug classes were tested. 
Therefore, we decided that the Plan does not have to pay for the drug test(s) 22 or more drug class(es), 
including metabolite(s) if performed (CPT code G0483) provided on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing (81455) provided April 16, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed date of service. 
 
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. The documentation does not support the billed date of service. Based 
on this information, we decided that Medicare rules for coverage of the lab testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing (81455) provided April 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents (72148). 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. The Plan denied your request. The 
Plan says the requested MRI is not medically necessary. 
 
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 of the spinal canal and 
contents. Our reviewer says that the medical necessity of the requested MRI of the lumbar spine has not been 
established. Our physician reviewer found you have a cervical spine implanted stimulator that was placed in 
2018. There is a high probability that an MRI would be contraindicated with this implanted device present. Our 
reviewer also found that you have left radicular pain but no neurological deficit or red flag, and you have no 
contraindication to physical therapy. 
 
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 of the spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents (72148).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron. 
 
You asked the Plan to pre-approve Lupron. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Lupron. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Eligard before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Lupron.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access (CPT code 
76937) provided on January 12, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. As the CPT code 76937 was billed 
without an appropriate primary code and not performed by the same practitioner on the same date of service; 
we find that Medicare rule for payment for CPT codes 76937 has not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound guidance for vascular access (CPT code 76937) provided on 
January 12, 2022.