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

 
We decided that the Plan does not have to pre-approve implantation of the CardioMEMS heart failure 
monitoring system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental/investigational indicates that there is insufficient good-quality evidence to 
show that the requested item or service is medically necessary and can reliably improve health outcomes. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure (CHF) in this 
patient. 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of the CardioMEMS heart failure monitoring system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
on August 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting a retro review for 
medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 the unlisted molecular pathology procedure 
(81479) provided on August 15, 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 the Optimizer Smart Implantable Pulse Generator (IPG). 
 
You asked the Plan to pre-approve the Optimizer Smart Implantable Pulse Generator (IPG). You say that the 
Optimizer Smart Implantable Pulse Generator (IPG) is medically necessary. The Plan denied your request. The 
Plan says the Optimizer Smart Implantable Pulse Generator (IPG) is experimental. 
 
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 Optimizer Smart Implantable Pulse 
Generator (IPG). Our reviewer says that the requested Optimizer Smart Implantable Pulse Generator (IPG) is 
not considered medically reasonable and necessary. Our physician reviewer found at issue is whether 
implantation of the CCM system in this enrollee is medically necessary for the treatment of CHF which has 
been deemed refractory to optimal medical therapy. 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. At the current time, I would not consider the CCM system to be 
medically necessary in this 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 the Optimizer Smart Implantable Pulse Generator (IPG) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse 
Generator (IPG).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services rendered on January 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that procedure codes 88305, J2001, J2704, J7120, and 43237 are included in the primary 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that codes 88305, J2001, J2704, J7120, and 43237 are included 
in the primary procedure; however, there is no Explanation of Benefits (EOB), claim, or other documentation 
showing which primary procedure was billed. The Plan has not provided any documentation to support that the 
codes at issue are not payable as billed. Therefore, we decided that the Plan has to pay for the outpatient 
hospital services rendered on January 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1399). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you have very weak knees and 
cannot stand and walk for long. You would like to be able to move around and not be stuck at home getting 
depressed. The Plan denied your request. The Plan says you asked for a scooter to use in the community and do 
not meet criteria for approval. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an attendant 
control (E2331). 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300) and an attendant control (E2331). 
You say that the requested power seat elevation feature (E2300) and an attendant control (E2331) are medically 
necessary. The Plan denied your request. The Plan says the requested power seat elevation feature (E2300) and 
an attendant control (E2331) 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 an attendant control (E2331). Our 
reviewer says that the enrollee does not meet criteria for an attendant control (E2331). Our physician reviewer 
found the member has a neurologic disorder with functional deficits. The requested electrical accessories are 
not medically necessary as the member does have use of the upper extremity and can operate and control the 
power options using the switches that are included in the basic wheelchair.  
Furthermore, Medicare specifically excludes coverage of power seat elevation systems coded as E2300. 
 
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 power seat elevation feature (E2300) and an attendant control (E2331) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature 
(E2300) and an attendant control (E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flow cytometry (88184, 88185, 99299) and 
mononuclear cell antigen (86356). 
 
You asked the Plan to pre-approve flow cytometry and mononuclear cell antigen. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that flow cytometry is covered under certain 
circumstances. 
 
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 flow cytometry and mononuclear cell 
antigen. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this 
case, there is no specific clinical rationale for the requested laboratory study. The review has determined that 
the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flow cytometry and mononuclear cell antigen have not been met. Therefore, we 
decided that the Plan does not have to pre-approve flow cytometry (88184, 88185, 99299) and mononuclear 
cell antigen (86356).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053) blood count; 
complete (CBC), automated (85025) provided on August 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee is in a nursing facility and does 
not have the option on what lab service is used. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 the comprehensive metabolic panel (80053) blood 
count; complete (CBC), automated (85025) provided on August 10, 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 transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve the services. You say that this service is medically necessary in this specific 
situation. The Plan denied your request. The Plan says the requested device 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 at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure (CHF) in this 
patient. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor for long-term 
hemodynamic monitoring (CardioMEMS) (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service September 
20, 2021. 
 
You asked the Plan to pay for procedure code G0482. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code G0482 is bundled into payment for code 83520.  
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 G0482 
is a column II code to column I code 83520. 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 G0482 billed for date of service September 20, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Immune Globulin (Privigen) injections (J1459). 
 
You asked the Plan to pre-approve Privigen. The Plan denied your request. The Plan says the diagnoses do not 
meet the requirements for a medically accepted indication, and this request has been denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Privigen. Our reviewer says that 
Immune Globulin (Privigen) injections are not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of Methicillin-Resistant 
Staphylococcus aureus nasopharyngitis with a history of chronic lymphocytic leukemia. The FDA has not 
stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that 
the requested service cannot be 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 Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Immune Globulin (Privigen) injections (J1459).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (CGM). 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the criteria for a CGM have not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 provide a continuous glucose monitor (CGM). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the criteria for a 
continuous glucose monitor (CGM) are not met. 
 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 continuous glucose monitor (CGM) have not been met. Therefore, we decided 
that the Plan does not have to provide a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 9, 2022, billed with 
codes 81235, 81275, 81210, and 81206. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 9, 2022, billed with codes 81235, 81275, 81210, and 81206.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy sessions (90837) provided March 
1, 2022, to July 19, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that please reprocess as your provider is in-
network per the credentialing department. The Plan denied your request. The Plan says this provider type is not 
a part of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy sessions 
(90837) provided March 1, 2022, to July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 30, 
2022. 
  You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment 
for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SMART Cardiac Contractility Modulation (CCM) 
device (0408T). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is whether implantation of the CCM system in this patient is medically necessary 
for the treatment of CHF which has been deemed refractory to optimal medical therapy. 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the SMART Cardiac Contractility Modulation (CCM) device (0408T).