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

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the 
heart. 
 
You asked the Plan to pre-approve a CTA scan of the heart. You say that this imaging service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 CTA scan of the heart. Our reviewer 
says that the requested CTA scan is not medically reasonable and necessary. Our physician reviewer found at 
issue is the medical appropriateness and necessity of coronary CTA in the clinical evaluation of this patient. 
The claimant had a radionuclide stress test in March 2022 which was negative for ischemia. Clinical guidelines 
for the use of coronary CTA have not been met based on review of the submitted clinical documentation. As a 
result, at this time coronary CTA would not be considered medically reasonable and necessary in this patient'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 a CTA scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography angiography (CTA) scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient needed these services, and this should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 provided on February 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming of 
sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T). 
 
 
You asked the Plan to pre-approve an Optimizer SMART Cardiac Contractility Modulation (CCM) device. 
You say that you are seeking determination of coverage based on medical necessity for the requested device. 
The Plan denied your request. The Plan says the enrollee does not meet FDA Indications for use of the 
Optimizer Smart device. In addition, the most recent 2022 ACC/AHA Guidelines do not include the Optimizer 
device in their recommendations and the device has no data showing a decrease in hospitalizations or reduction 
in mortality. There is no indication that this enrollee is enrolled in a clinical trial of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Optimizer SMART Cardiac 
Contractility Modulation (CCM) device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found an exhaustive review of the 
current medical literature pertaining to the CCM system confirms multiple observational studies suggesting 
clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, 
along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful 
improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA 
approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. 
 
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 Optimizer SMART Cardiac Contractility Modulation (CCM) device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an insertion or replacement of 
permanent cardiac contractility modulation system, including contractility evaluation when performed, and 
programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
April 26, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you shouldnt have 
to pay for this. 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 20% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 Durable medical equipment provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 2, 
2022, 
 
You asked the Plan to waive the copayment for laboratory services. You say that you feel you should not have 
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 $15 
copayment for outpatient diagnostic tests/laboratory and non-radiological diagnostic tests.  
 
You have been asked to pay a $15 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/laboratory and non-radiological diagnostic tests 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 laboratory services provided on June 2, 2022,
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on April 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 9, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you said you were not seen 
fast enough so u left the hospital and should not have to pay 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 $200 
copayment for ambulance services/one-way trip for emergency ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance services. This item/service falls within the 
ambulance services/one-way trip for emergency ambulance 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 ambulance services provided on July 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary and the patient has failed conservative therapy. The Plan denied your request. The Plan says the 
patient does not meet criteria for this device. 
 
The Plan follows Medicare rules. Medicare rules say that in order for a pneumatic compression device to be 
covered, the patient's medical records must document specific conditions.  There must be clinical evidence of trial and failure of conservative therapy. 
 
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 pneumatic compression device. Our 
reviewer says that the patient does not meet coverage criteria for a pneumatic compression device. Our 
physician reviewer found a letter of medical necessity, vendor-prepared documents and a standard written order 
were submitted reporting lymphedema unresponsive to conservative treatment but no clinical records including 
a history of present illness, past medical history and physical examination, assessment and treatment plan were 
submitted to support the orders written.  
 
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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
June 17, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that the $150 copayment is 
the same as if you had been admitted to the hospital and you feel the charge is unwarranted. 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 $150 
copayment for outpatient hospital services. 
 
You have been asked to pay a $150 copayment for outpatient surgery services. 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 copayment for 
outpatient surgery services provided on June 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urgent care services provided from April 6, 2022, to 
April 9, 2022. 
 
You asked the Plan to pay for the urgent care services. You say that you broke your leg, and you would like the 
Plan to pay for the services. The Plan denied your request. The Plan says The enrollee did not include a receipt 
of payment or medical records as required for processing; therefore, the denial for payment is correct. 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the urgent care services have been met. 
There was no medical documentation submitted to prove the medical necessity of the urgent care services. 
Therefore, we decided that the Plan does not have to pay for the urgent care services provided from April 6, 
2022, to April 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room services provided from 
August 3, 2022. 
 
You asked the Plan to waive the copayment for an emergency room services. You say that you feel that the 
copayments are adding up. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room services. This item/service falls within 
the emergency 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 an emergency room 
services provided from August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on March 7, 2022, to June 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the services were medically necessary, and 
you are appealing with supporting documentation. 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 chiropractic services provided on March 7, 2022, 
to June 21, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this imaging is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no 
medical necessity for the requested CT scan. 
 
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 the requested CT scan is not medically reasonable and necessary. Our physician 
reviewer found Patient has symptoms suspicious for esophageal stricture and esophagogastroduodenoscopy has 
been considered. Change in diet has been considered likely responsible for the weight loss. No colonoscopy for 
this patient with prior history of cecal polyp and there is no record of testing for fecal blood. The request for a 
CT scan should be considered after an appropriate gastrointestinal workup for this patient with prior cecal 
polyp and possible esophageal stricture. 
 
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 not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatry visit provided on July 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a psychiatry visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 a psychiatry visit provided on July 25, 2022, by an 
out-of-network (OON) provider.
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 an LTACH is the best chance for the 
enrollee's quick recovery. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. The Plan says that the enrollee's current setting is appropriate, as her blood cultures remain positive and 
due to the possibility that the subclavian catheter may need replacement. 
 
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 the enrollee appears to be more stable and improving now and should only require 
short-term additional acute care services that can safely be provided at the current facility, including additional 
weaning, until more stable and 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.