Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for health and wellness education and fitness program services 
by an out-of-network facility from January 10, 2020, to March 4, 2021. 
 
You asked the Plan to pay for the health and wellness education and fitness program services. You say that you 
are benefiting from the program and should be reimbursed. The Plan denied your request. The Plan says the 
services were provided from a non-participating provider and not authorized in advance. 
 
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 for a basic membership to a SilverSneakers participating fitness facility.  
 
The Plans rules for coverage of gym benefits have not been met because the gym is not a participating 
SilverSneakers fitness facility. Therefore, we decided that the Plan does not have to pay for health and wellness 
education and fitness program services by an out-of-network facility from January 10, 2020, to March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dorzolamide-Timolol drops. 
 
You asked the Plan to pre-approve Dorzolamide-Timolol drops. You say that this medication is medically 
necessary. The Plan denied your request. The Plan says this medication is not a covered benefit because it is a 
self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dorzolamide-Timolol 
drops.  
 Benefits for Dorzolamide-Timolol drops may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman procedure (CPT code 33340) and an 
inpatient admission.  
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the records do not show that the 
enrollee is unable to take blood thinners on an ongoing basis. The Plan states the enrollee is currently taking a 
blood thinner without any medical problems. 
 
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 physician reviewer 
found there is no apparent contraindication to anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollee'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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Watchman procedure (CPT code 33340) and an inpatient admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PAE (a procedure to reduce the blood flow to the 
prostate) (CPT code 37243). 
 
You asked the Plan to pre-approve the service. You say that the enrollee needs this procedure in order to be 
able to find out how to regain maximum functions. The Plan denied your request. The Plan says the procedure 
requested is still in clinical trials and is not yet shown to be more effective in the treatment of benign prostatic 
hyperplasia (BPH). 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found prostate artery embolization (PAE) is not medically reasonable and necessary in this case. PAE 
is considered an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated 
possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure 
outside of a clinical trial 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PAE (a procedure to reduce the blood flow to the prostate) (CPT code 37243).
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a 
lower level of care may be considered when treatment has completed. 
 
 
 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. At the 
current level of function, the enrollee's rehab can be safely provided at a lower intensity and alternate setting in 
a skilled nursing facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. At the current medical 
stability, your rehab can be safely provided at a lower intensity and alternate setting in a skilled nursing facility. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable automatic cardioverter defibrillator 
(ICD). 
 
You asked the Plan to pre-approve an ICD. You say that the enrollee has documented ventricular fibrillation 
which can cause cardiac arrest. The appellant says that the enrollee is currently wearing a life vest. The Plan 
denied your request. The Plan says the clinical documentation provided does not show that the enrollee has one 
of the six covered indications for the requested treatment. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of a defibrillator is covered when 
medically reasonable and necessary for certain clinical indications.  
 
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 ICD. Our reviewer says that the 
implantation of an automatic defibrillator is not considered medically reasonable and necessary in the 
management of this enrollee. Our physician reviewer found the clinical documentation provided shows 
evidence of malfunction of pacemaker lead, in setting of normal ventricular function, consistent with a need for 
lead revision rather than defibrillator implant. The evidence does not show that the enrollee meets implant 
criteria for defibrillator insertion according to current guidelines. 
 
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 ICD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable automatic cardioverter defibrillator (ICD).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 47361) provided to the 
enrollee on August 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 47361 is not supported by the medical records submitted. 
 
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, the CPT Code Manual definition of code 47361 is "Management of liver hemorrhage; exploration 
of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report does not support 
CPT 47361, as no debridement is documented per CPT code description. Of note, the operative report describes 
a complication as a result of the surgery, which would not be separately reportable. 
 We looked at this coder'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 pay for surgical services (procedure code 47361) provided to the enrollee on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and office visit provided on 
October 14, 2021. 
 
You asked the Plan to waive the copayment for the x-ray and office visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $20 
copayment for Physician/Practitioner services, including doctors office visits and a $10 copayment for 
Outpatient diagnostic tests and therapeutic services and supplies. 
 
  You have been asked to pay a $20 copayment for a specialist office visit and a $10 copayment for an x-ray. 
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 x-ray and office visit provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular services (procedure code 36252) provided to the 
enrollee on September 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support a diagnosis for which this service would be indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 
services are not medically reasonable or necessary. Our reviewer found the service in question is CPT code 
36252. This codes for diagnostic renal angiography.  There is no documentation in the medical records 
provided suggesting that renal angiography was being considered, necessary, or even performed. A review of 
the operative note demonstrates that lower extremity arterial occlusive disease was being treated. There was no 
mention of the renal arteries. 
 
 We looked at this 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 pay 
for the vascular services (procedure code 36252) provided to the enrollee on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
November 30, 2021, to December 11, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 854 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH CC). 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found the more appropriate DRG in this case would be 603 (CELLULITIS 
WITHOUT MCC). Although it is acknowledged the enrollee had support via diagnostic data and provider 
documentation of a localized infection of cellulitis with the elevation of HR and fever, the enrollee was without 
diagnostic signs or provider documentation of organ dysfunction in the medical record provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on November 30, 2021, to December 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasonic guidance (76998) provided on  
December 17, 2020. 
 
You asked the Plan to pay for code 76998. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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, the CPT Code Manual definition of code 76998 is Ultrasonic guidance, intraoperative. 
 
We find that CPT code 76998 is not supported in the medical record. Specifically, the description of code 
76998 was not documented in the operative report narrative. Based on this information, we decided that Medicare rules for coverage of code 76998 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Ultrasonic guidance (76998) provided on December 17, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Selective catheter placement (36215) and Angiography (75710) 
provided on July 13, 2021. 
 
You asked the Plan to pay for codes 36215 and 75710. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 codes 
36215 and 75710 are not column II codes to column I code 36902. The rules also say that Medicare plans must 
make reasonable and diligent efforts to gather and forward information to the Independent Review Entity 
(IRE). The Plan provided no evidence that these codes cannot be paid as billed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 36215 and 75710 have been met. Therefore, we decided that the Plan has to pay for the 
Selective catheter placement (36215) and Angiography (75710) provided on July 13, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP Vaccine (90715, 90471) provided November 8, 
2021. 
 
You asked the Plan to pay for the vaccination. You say that this vaccine was medically necessary. The Plan 
denied your request. The Plan says this service is not eligible for coverage under the Part B medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccination. 
Therefore, we decided that the Plan does not have to pay for a TDAP Vaccine (90715, 90471) provided 
November 8, 2021.  
 
Benefits for the vaccination may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 is improving but requires ongoing critical care services and these have 
not been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
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.