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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, the enrollee has moderate pain that has responded to prior ESI therapy with 50 to 60% pain relief 
lasting for only 2 months. The review has determined that the requested epidural steroid injection does not 
meet the Medicare LCD coverage criteria. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706) provided on July 11, 2022. 
 
You asked the Plan to pay for the AAA. You say that this service was performed at the request of the referring 
provider. You also say that it is medically necessary. The Plan denied your request. The Plan says the service 
was not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that an ultrasound screening for abdominal aortic 
aneurysms is considered medically reasonable and necessary when a beneficiary meets the criteria. 
 
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 AAA. Our reviewer says that the 
requested AAA is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has a history of hypertension but has no pertinent signs or symptoms. The reviewer found 
that there is no evidence to suggest a need to perform the requested aortic ultrasound study. Therefore, the 
reviewer found that the requested AAA is not medically 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 AAA have not been met. Therefore, we decided that the Plan does not have 
to pay for the ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal 
aortic aneurysm (AAA) (76706) provided on July 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the oxaliplatin injection (J9263) provided on July 25, 2022. 
 
You asked the Plan to pay for oxaliplatin. You say that this should be paid. The Plan denied your request. The 
Plan says that the charge in this claim was included in the facility rate that had already been paid. 
 
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. Specifically, the file does not support the plan's reason for denial. Therefore, we 
decided that the Plan has to pay for the oxaliplatin injection (J9263) provided on July 25, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a DaTscan. 
 
You asked the Plan to pre-approve a DaTscan. You say that a DaTscan is medically necessary. The Plan denied 
your request. The Plan says that a DaTscan is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a DaTscan. Our reviewer says that the 
requested DaTscan considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee is a 79-year-old man with a six-month history of progressive ataxia, tremors and dysphonia.  
Conventional imaging has been done. The neurologist's differential includes probable multi system atrophy but 
Parkinson's disease also possible. A DaTscan has been requested to evaluate for Parkinson's disease.  This scan 
is a Dopamine evaluation and is useful to diagnose Parkinson's disease.  If positive, appropriate treatment for 
Parkinson's disease will ensue. If negative, supportive measures only will be appropriate. The reasoning of the 
neurologist to evaluate for a treatable disease is in the best interest of the enrollee and the requested DaTscan is 
the best means to do so. This technology is well known as a movement disorder evaluation and is supported as 
useful in the literature.  
 
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 DaTscan have been met. Therefore, we decided that the Plan has to pre-
approve a DaTscan.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for the COVID-19 home test kits provided on 
February 9, 2022. 
 
You asked the Plan to pay the full cost for the COVID-19 home test kits. You say that you would like to be 
reimbursed the full amount for the at-home COVID-19 tests. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 home test kits is an OTC item. Specifically, the Plan paid more than what is required under the 
benefit. Therefore, we decided that the Plan does not have to pay the full cost for the COVID-19 home test kits 
provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on July 14, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as prior 
authorization was not obtained.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on July 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95806). 
 
You asked the Plan to pre-approve a sleep study. You say that the service is necessary. The Plan denied your 
request. The Plan says the service 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 sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records document that you have a body mass index of 38.15 kg/m2 as of November 16, 
2022. You do not qualify for a hypoglossal nerve stimulator under Medicare rules as your body mass index is 
greater than 35 kg/m2. As you do not qualify presently for a hypoglossal nerve stimulator, then the repeat sleep 
study for evaluation for a hypoglossal nerve stimulator does not meet Medicare criteria for medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. You do not meet the criteria for the 
hypoglossal nerve stimulation, and therefore, the sleep study is not medically necessary. Based on this 
information, we decided that Medicare rules for coverage of a sleep study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sleep study (95806).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that an implantable loop recorder is 
medically necessary. The Plan denied your request. The Plan says an implantable loop recorder.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 an implantable loop recorder. Our 
reviewer says that the requested implantable loop recorder is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that while the enrollee has a history of atrial fibrillation 
and orthostatic dizziness, there is no documentation provided to suggest a history of recent unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. In summary, 
there is insufficient documentation to support the medical necessity for insertion of an implantable loop 
recorder in this enrollees 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Implantable Loop Recorder. 
 
You asked the Plan to pre-approve an Implantable Loop Recorder. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Implantable (or Insertable) Loop Recorder (ILR): 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patient's upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac related but is too 
infrequent to be detected by either a Holter monitor or a traditional pre-symptom MLR. 
 
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 Implantable Loop Recorder. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found While the patient has a 
history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. 
 
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 Implantable Loop Recorder have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Implantable Loop Recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered 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 an intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99140 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF system. 
 
You asked the Plan to pre-approve the CardioMEMS HF system. You say that the CardioMEMS HF system is 
medically necessary. The Plan denied your request. The Plan says the CardioMEMS HF system 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 CardioMEMS HF system. Our 
reviewer says that the CardioMEMS HF system is not medically necessary. Our physician reviewer found the 
CardioMEMS HF device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a 
sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was 
based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS HF system was implanted, reflecting a patient population with preserved ejection fraction and 
was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of the CardioMEMS HF system. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of the CardioMEMS HF system in patient management. As a result, at this time the CardioMEMS HF 
system would not be considered medically appropriate and necessary in this enrollees 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 HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention (D2951) provided on January 31, 2022, to April 
25, 2022. 
 
You asked the Plan to pay for pin retention. You say that this provider was in-network. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pin 
retention (D2951) provided on January 31, 2022, to April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device and related 
accessories. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
enrollee does not have a covered condition for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that continuous positive airway pressure devices are only 
covered under certain medical 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 the requested services. Our physician 
reviewer found that the enrollee had a home sleep study on September 8, 2022, which showed mild OSA, with 
an AHI of 11.6. The clinical visit on October 17, 2022, includes diagnoses of insomnia, coronary artery 
disease, and congestive heart failure, meeting Medicare criteria for treatment of mild OSA. Therefore, a CPAP 
is reasonable and medically necessary for 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a continuous positive airway pressure (CPAP) device and related accessories.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 12, 2022, 
through July 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 The Plan follows Medicare Rules. Medicare rules say that an inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 these services. Our reviewer says that the 
acute inpatient hospital care provided was not medically necessary. Our physician reviewer found that the 
enrollee presented to the hospital on July 12, 2022. She was diagnosed and treated for pneumonia, acute kidney 
injury, and anemia. She was noted to have been non-compliant with home treatments including oxygen. This 
was recently following a recent admission for pneumonia, hypoxic respiratory failure, acute kidney injury, and 
anemia. She was discharged for about one week prior to the readmission for worsening shortness of breath. She 
was treated with low dose oxygen support in the emergency department and was no longer in respiratory 
distress. She was advised to use oxygen all the time at home to prevent hypoxia/dyspnea. The readmission was 
not medically necessary as the enrollee could have been monitored in observation care for home oxygen dosing 
and monitoring with instruction prior to discharge again. The enrollee was stable on admission. The 
readmission did not result from a premature discharge from the same hospital, but rather from non-compliance 
of the enrollee with her home oxygen treatments.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 12, 2022, through July 14, 2022.