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

 
We decided that the Plan does not have to pre-approve allograft for spine surgery only structural identified with 
code 20931, arthrodesis anterior interbody including disc space preparation discectomy osteophytectomy and 
decompression of spinal cord and/or nerve roots cervical below C2 identified with code 22551, and anterior 
instrumentation 2 to 3 vertebral segments identified with code 22845. 
 
You asked the Plan to pre-approve these surgery services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested 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 these surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has spinal stenosis. There is no documentation of conservative measures for C5-6 DDD findings above the previous fusion. More conservative measures such as physical therapy and 
injection therapy are needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft for spine surgery only structural identified with code 20931, arthrodesis 
anterior interbody including disc space preparation discectomy osteophytectomy and decompression of spinal 
cord and/or nerve roots cervical below C2 identified with code 22551, and anterior instrumentation 2 to 3 
vertebral segments identified with code 22845.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-
assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive 
airway pressure (BiPAP) is not covered. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with average volume-assured pressure support (AVAPS) and auto-EPAP capability. The plan has 
indicated such a device is available for coverage. The elements of the coverage criteria are not satisfied. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture treatment provided on November 1, 2021.
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for all items and services provided on November 4, 
2021. 
 
You asked the Plan to waive the coinsurance for all items and services. You say that you are on a fixed income 
and that paying this bill will be an extreme hardship. The Plan denied your request. The Plan says that you have 
been charged the correct cost sharing amount. 
 
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 did not provide information showing what the $1,270.23 charge on line 
two of this claim was for. Without that information we are unable to determine if the cost sharing applied is 
correct. 
 
The Plan says you must pay 20% coinsurance for all other items and services. According to Medicare, the 
remaining codes on this claim that applied a cost sharing amount are considered packaged codes and are not 
separately payable. Therefore, we decided that the Plan has to waive the coinsurance for all items and services 
provided on November 4, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ancillary intraoperative neuromonitoring (IONM) services (95938, 95909, 95886, 95940, A4215, A4556) provided on September 22, 2021.
You asked the Plan to pay for IONM services. You say that these services were billed appropriately and should be paid. The Plan denied your request. The Plan says this provider is not eligible to accept Medicare payment.
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 eligible to enroll in the Medicare program and bill directly. Therefore, we decided that the Plan does not have to pay for ancillary intraoperative neuromonitoring (IONM) services (95938, 95909, 95886, 95940, A4215, A4556) provided on September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient office visit (99221) provided January 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that services were authorized by the Plan. Multiple 
claims denied for dates of service 01/08/2022 and 01/10/22. Submitting medical administrative appeal with 
clinical documentation. The Plan denied your request. The Plan says that the claim was processed with the 
correct cost share applied per the Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that there is no 
coinsurance, copayment or deductible for Medicare covered physician/practitioner services (including 
telehealth services and urgently needed services.  
 
The Plan says the enrollee must pay $97.79 coinsurance for the office visit. Based on the plan contract, 
however, there is no coinsurance, copayment or deductible for Medicare covered physician/practitioner 
services (including telehealth services and urgently needed services for the office visit. Therefore, we decided 
that the Plan has to pay for the outpatient office visit (99221) provided January 8, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS Heart Failure (HF) System. You say that the enrollee 
urgently needs this device and procedure due to her worsening heart failure and multiple emergency room 
visits for dyspnea. The Plan denied your request. The Plan says the CardioMEMS HF System is considered 
investigational or experimental unless it is implanted as part of an approved clinical trial. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are 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 the CardioMEMS Heart Failure (HF) System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT code 33289).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (87150) provided on March 17, 2021.
You asked the Plan to pay for laboratory testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for laboratory testing (87150) provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the CardioMEMS device is considered unproven and 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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are 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 HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (CPT code(s): 33289 and C2624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zip Spine interspinous-interlaminar fusion device (CPT
code(s): 22612 and 22614).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational as it is not identified as widely used and generally accepted for the proposed
use as reported in nationally recognized peer-reviewed medical literature published in the English language
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 Zip fusion interlaminar device is experimental for spinal fusion. More research is needed.
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 Zip Spine interspinous-interlaminar fusion device (CPT code(s): 22612 and 22614).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a next generation sequencing panel provided to the enrollee 
on July 9, 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 panels that include the FANCC gene are not covered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found FoundationOne CDx testing analyzes 324 genes, as well as genomic signatures including microsatellite 
instability and tumor mutational burden. The documentation does not support that the enrollee had recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. The clinical documentation does not support that the testing was medically reasonable and necessary for the enrollee in this case. 
 
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 pay for a next generation sequencing panel provided to the enrollee on July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have documented skilled nursing needs or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable cervical collar rendered on January 24, 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 there is no valid detailed written order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the adjustable cervical collar rendered on 
January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this equipment was exclusively 
given and used by the enrollee in their home. This equipment is separate from the enrollee's surgery and should 
not be included in the surgery fee. The Plan denied your request. The Plan says pneumatic compression device 
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass 
grafts (93926) interrogation device evaluation (in person) with physician analysis, review and report (93291) 
provided on March 22, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that say the medical records provided support 
the necessity of the services in dispute. 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 duplex scan of lower extremity arteries or arterial 
bypass grafts (93926) interrogation device evaluation (in person) with physician analysis, review and report 
(93291) provided on March 22, 2022 by an out-of-network (OON) provider.