Persius/hicric huggingface dataset:
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 a CardioMEMS device. You say that the requested surgery is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is 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 patients 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #3. 
 
You asked the Plan to pay for the services. You say that there was insufficient tooth structure remaining, so a 
crown and core buildup was necessary. The Plan denied your request. The Plan says the services were for 
preventative reasons and not to treat active dental disease. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found that based 
on the supplied documentation there is no medical necessity for the requested services. There is an existing three surface restoration present on tooth #3. Part of the restoration is in amalgam, part in composite, with the 
amalgam part showing signs of wear. The provider noted that decay was removed after the filling was taken 
out, and that a crown and core buildup was necessary. Given the x-ray view provided, there is not extensive 
breakdown of the tooth structure and no apparent recurrent decay such that a crown and core buildup would be 
necessary. Generally, 50% or more of the structure should be missing before a crown is considered. A core 
buildup is only needed if there is insufficient structure remaining to retain a crown. It would be impossible to 
conclude that a core buildup would be necessary from the provided information even if a crown was needed. 
From the provided information, it cannot be determined that there is sufficient missing structure as to require a 
crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a crown (D2740) and core buildup (D2950) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 12, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $30 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on December 05, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on December 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient appears to be responding to treatment but currently still somewhat 
unstable and should only require short-term additional acute care services that can safely be provided at the 
current facility until more stable and appropriate for a lower level of care. The patient 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 admission to a long-term acute care hospital (LTACH).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex superion interspinous 
spacer at L3-4 and L4-5, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869 and 22870).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve irinotecan (J9206). 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested drug is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that xeloda and irinotecan 
are National Comprehensive Cancer Network (NCCN) and compendia supported as second line therapy for 
metastatic colon cancer. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
irinotecan (J9206).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there are no pulmonary 
function tests to confirm severity. There is also a diagnosis of obstructive sleep apnea, and the patient is 
severely obese. There is no arterial blood gas, done while stable, to document chronic CO2 retention, so the 
patient does not qualify for a ventilatory assist device (other than continuous positive airway pressure - CPAP). If the patient does have chronic CO2 retention, they may benefit from bilateral positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep. However, Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services provided on April 23, 2021, billed with 20 units of 
code 11046. 
 
You asked the Plan to pay for the surgical services as billed. You say that this is billed correctly and should be 
paid. The Plan denied your request. The Plan says that the number of units billed exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with an MUE with MAI of 3, payment 
can be made for units exceeding the MUE if there is evidence that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
We looked at the file and Medicare rules. Review of the operative report documents that the wound being 
treated was 34cm by 12cm. This is a total area of 408 square cm. The reported number of units corresponds to 
up to 420 square cm. This number of units is clearly documented as having been performed. There is no 
argument raised by the Plan that treatment of the entire wound of that size was not medically necessary. As 
such, we find that the MUE being exceeded is supported in this case. Based on this information, we decided 
that Medicare rules for coverage of the surgical services as billed have been met. Therefore, we decided that the 
Plan has to pay for the surgical services provided on April 23, 2021, billed with 20 units of code 11046.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychotherapy visits (90832, 90834 and 90837). 
 
You asked the Plan to pre-approve the outpatient mental health visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there is no indication that the enrollee needs further 
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 the outpatient mental health visits. Our 
physician reviewer found the records provided this enrollee is not showing any symptoms of her illness which 
would require the patient to be seen for individual psychotherapy. The psychotherapy performed was not found 
to be reasonable or medically necessary utilizing LCD L34616. 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 outpatient 
mental health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
psychotherapy visits (90832, 90834 and 90837).
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says IRF services are not medically necessary. 
 
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 that the enrollee is deconditioned secondary to progressive chronic illness. The 
enrollee does not require intensive therapy services or complex rehabilitation services. The enrollee does not 
require frequent physiatry oversight.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the trifocal lens provided on June 30, 2022. 
 
You asked the Plan to pay for the frames and the trifocal lens. You say that you have been treated by this 
doctor for years and have never had an issue getting reimbursed for glasses. The Plan denied your request. The 
Plan says the provider was out-of-network.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the frames and the trifocal lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames and the trifocal lens provided on June 
30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the spine provided 
on August 04, 2022. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI) of the spine. You say that you are not 
required to obtain authorization per the contract. The Plan denied your request. The Plan says that 
unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the magnetic resonance 
imaging (MRI) of the spine provided on August 04, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the request meets all of 
the LCD criteria. The request is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 heavy duty, multiple power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862) and the other requested 
items/accessories (E0955, E0956, E1007, E1012, E1028 X 5, E2300, E2311, E2313, E2363, E2377, E2607 and 
E2620). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the notes do not show that the enrollee needs both of these power options. The Plan 
states the upgraded electronics (expandable controller, harness and electronic connector) are not medically 
necessary. The Plan states they cannot be covered. The Plan states the seat lift does not serve a medical purpose 
and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the enrollee is not at high risk for skin breakdown, does not use a catheter or have significant spasticity 
require special positioning and has adequate upper body strength to manage standard switches, per L33789 and 
functional status as recorded in the record. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient 
weight capacity 301 to 450 pounds (K0862) and the other requested items/accessories (E0955, E0956, E1007, 
E1012, E1028 X 5, E2300, E2311, E2313, E2363, E2377, E2607 and E2620).