Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health treatment services to be provided by 
you as in-network. 
 
You asked the Plan to pre-approve behavioral health treatment services to be provided by you as in-network. 
You say that the enrollee is diagnosed with dissociative identity disorder due to a history of multiple traumas 
that have included sexual, physical and emotional abuse from a very early age. You say that you have been 
seeing the enrollee for almost ten years because due to her trauma history she has difficulty establishing 
therapeutic trust, which is essential to therapeutic progress and she also has extremely limited financial 
resources as she is on disability and her husband is often unemployed, which means that in addition to 
therapeutic concerns this change will seriously impact her financially. The Plan denied your request. The Plan 
says the Out-of-Network Exception for Psychotherapy does not meet the criteria and there are in-network 
providers that can provide this service.  
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program 
Therefore, we decided that the Plan does not have to pre-approve behavioral health treatment services to be 
provided by you as in-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transmitter (A9277) and sensors (A9276). 
 
You asked the Plan to pre-approve the transmitter and sensors. You say that you would like reconsideration 
because the requested supplies are medically necessary. The Plan denied your request. The Plan says the 
requested device is not a covered device and therefore the supplies are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that adjunctive CGM disposable supplies which fall 
under the DME benefit must be billed with code A4238 for the supply allowance. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transmitter and sensors have not been met. The requested device is not covered and the codes 
requested are not valid for coverage. Therefore, we decided that the Plan does not have to pre-approve the 
transmitter (A9277) and sensors (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the durable medical equipment 
(DME) purchased on March 17, 2021, and March 26, 2021. 
 
You asked the Plan to provide additional reimbursement for the DME purchased. You say that you feel that 
you should be reimbursed a higher share of what you spent. The Plan denied your request. The Plan says this 
was paid less your cost sharing for DME, and less sales tax which is not paid by Medicare. 
 
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 18% coinsurance for durable medical equipment (DME).  
 
You have been asked to pay 18% coinsurance for the DME purchased. The sales tax was not included per 
Medicare rules. 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 provide additional reimbursement for the durable medical equipment 
(DME) purchased on March 17, 2021, and March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of a permanent cardiac 
contractility modulation system. 
 
You asked the Plan to pre-approve insertion or replacement of a permanent cardiac contractility modulation 
system. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
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 insertion or replacement of a permanent 
cardiac contractility modulation system. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found while the clinical studies led to 
FDA approval in 2019, cardiac contractility modulation (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, the CCM system is not considered 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 insertion or replacement of a permanent cardiac contractility modulation system 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or replacement 
of a permanent cardiac contractility modulation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due 
to worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because CardioMEMS has been determined to have uncertain value and carries a significant 
risk of complications including death. 
 
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 CardioMEMS. 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 the long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws (D0367), collection and application of autologous blood 
concentrate product (D7921), and bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation, collection and application of 
autologous blood concentrate product, and bone replacement graft. The Plan denied your request. The Plan 
says these services are not covered under the enrollee's benefit plan. 
 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 pre-approve a 
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367), 
collection and application of autologous blood concentrate product (D7921), and bone replacement graft for 
ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on May 16, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this was medically necessary testing. The 
Plan denied your request. The Plan says this was not billed with an appropriate POS code. 
 
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 the Tempus gene panel 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 the Tempus gene panel provided on May 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. 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 a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nivolumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. 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 Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
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 record does not document that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights at the time of admission. You may be admitted for 
observation. The elements of the coverage rule are not satisfied. The requested service is not 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fitting and placing of a post in tooth #20. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 pre-approve 
fitting and placing of a post in tooth #20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health outpatient telehealth therapy to be 
provided by the requested provider. 
 
You asked the Plan to pre-approve mental health outpatient telehealth therapy. The Plan denied your request. 
The Plan says this provider is not licensed in the state of New Hampshire. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve mental 
health outpatient telehealth therapy to be provided by the requested provider.
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 enrollee's ability to regain maximum function is 
in jeopardy if IRF is denied. The Plan denied your request. The Plan says the denial of authorization for IRF 
service is correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on September 7, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this testing is not included in payment for dialysis. 
The Plan denied your request. The Plan says Medicare does not make separate payment for these services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because the 
requested visit is medically necessary. The Plan denied your request. The Plan says there are in-network 
providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiology office visit to be provided by an out-of-network (OON) provider.
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 your mobility has improved, and a previous stay with 
this facility was very successful. You say you are requesting a few more weeks of therapy until you are able to 
have in-home therapy. The Plan denied your request. The Plan says authorization denied because IRF care is 
not medically necessary and your needs can be met at a lower level of care such as a skilled nursing facility 
(SNF), home with health services or home with outpatient therapy. 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacroiliac (SI) joint stabilization. 
 
You asked the Plan to pre-approve percutaneous SI joint stabilization. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 percutaneous SI joint stabilization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found percutaneous sacroiliac (SI) joint stabilization remains experimental. More 
research is needed to show safety and efficacy of this procedure to treat low back pain (LBP). There is no SI 
joint instability, fracture, or lesion documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous SI joint stabilization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous sacroiliac (SI) joint stabilization.