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

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system CardioMEMS) for management of congestive heart 
failure (CHF) in the enrollee. The CardioMEMS 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 CHF. The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS 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 CardioMEMS. Nonetheless, 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 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 device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not 
submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 25, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99283 is bundled into payment for code 99285. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve SSBCI services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the qualifying criteria for SSBCI benefits have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. The Plans contract specifies that you must be at high risk for 
hospitalization and require intensive care coordination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI services have not been met. Specifically, we have confirmed that you are not at high risk of 
hospitalization, and you do not require intensive care coordination. Therefore, we decided that the Plan does 
not have to pre-approve special supplemental benefits for the chronically ill (SSBCI) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter, a crutch substitute, lower leg platform, 
with or without wheels (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you just had ankle surgery on 09/20/22 and 
cannot get around to do everyday activities. You are in a lot of pain and do not want to worsen your ankle 
fracture. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute is not covered.  
 
While a knee scooter may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a knee scooter, a crutch substitute, 
lower leg platform, with or without wheels (E0118).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will need both nursing and 
respiratory assistance. You say that an LTACH level of care is the only option for a safe discharge and to 
manage their complex medical needs. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee can get the services they need in another setting. 
 
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 unstable and should only require additional acute care services that can 
safely be administered at the current facility. The enrollee does not require services at the LTACH that are not 
already available at the current 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hydrophilic, spherical contact lenses 
(V2520) provided on June 15, 2022. 
 
You asked the Plan to waive the copayment for hydrophilic, spherical contact lenses (V2520). You say that you 
never had the procedure. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $30 
copayment for one pair of Medicare-covered standard glasses or contacts after each cataract surgery.  
 
You have been asked to pay a $30 copayment for hydrophilic, spherical contact lenses (V2520). This 
item/service falls within the one pair of Medicare-covered standard glasses or contacts after each cataract 
surgery benefit category. 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 hydrophilic, spherical 
contact lenses (V2520) provided on June 15, 2022.   
Your complaint about this being classified as post-cataract surgery is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary level Hematology/Oncology services. 
 
You asked the Plan to pre-approve tertiary level Hematology/Oncology services. You say that tertiary level 
Hematology/Oncology is medically necessary. The Plan denied your request. The Plan says tertiary level 
Hematology/Oncology 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 tertiary level Hematology/Oncology 
services. Our reviewer says that the requested tertiary level Hematology/Oncology services is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not 
clearly show that the tertiary consultation was more appropriate than a lower level of care. There was 
insufficient evidence of high complexity, need for special treatment or testing, or that it would not be safe to 
continue treatment/discussion at a lower level of care. Therefore, this request for tertiary level 
Hematology/Oncology services will be considered not medically necessary based on the provided 
documentation.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tertiary level Hematology/Oncology services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve tertiary level Hematology/Oncology services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigeminal nerve block (64400), occipital nerve block 
(64405), and trigger point injections (20552, 20553). 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary. 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 the injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
did not indicate any trigger points on exam or similar signs of a myofascial pain syndrome. Therefore, the 
reviewer found that the trigger point injections are not be medically necessary. The reviewer found that there 
are not enough studies to support the success of nerve blocks. Therefore, the reviewer found that the requested 
occipital and trigeminal nerve blocks are not medically reasonable or necessary either. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve trigeminal nerve block (64400), occipital nerve block (64405), and trigger point injections 
(20552, 20553).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 8 additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules and the 
Plans contractual coverage language to determine if the Plan was correct in denying the request to pre-approve 
these services. Our reviewer says that the requested services are medically necessary. Our physician reviewer 
found that you have chronic low back pain and were using a walker for mobility. Your pain level was 10/10. 
You have had a series of acupuncture treatments. Your pain has been reduced to 7/10 and your mobility has 
increased as you are using a cane instead of a walker. The Plans contractual coverage states that, "A patient 
may be authorized to receive additional visits if, after a medical necessity review, the initial course of treatment 
is determined to have been beneficial. Significant efficacy in improvement either in the pain scale and/or 
functional scale should be demonstrated before any subsequent visits are authorized." You stated that you have 
gained pain relief and additional mobility. Therefore, you meet the criteria for additional acupuncture sessions. 
Your request for additional acupuncture treatment is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve 8 additional acupuncture treatments.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 6, 2022, to March 7, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the home 
health claim does not have an 'admission' date corresponding to the continuing care in 2022. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from February 
6, 2022, to March 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve hereditary breast cancer testing (81432 and 81433). 
 
You asked the Plan to pre-approve hereditary breast cancer testing. You say that this testing is medically 
necessary because you have a personal history of breast cancer. The Plan denied your request. The Plan says 
that the criteria for coverage of these tests are not met. 
 
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 hereditary breast cancer testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that this testing is indicated according to your personal history of breast cancer 
and a limited family history which includes a mother with kidney cancer. Testing is necessary to guide 
surveillance and treatment decision making (should you have certain genes/mutations given high risk disease). 
The requested testing is reasonable and 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 hereditary breast cancer testing have been met. Therefore, we decided that the 
Plan has to pre-approve hereditary breast cancer testing (81432 and 81433).  
 
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 insertion of non-indwelling bladder catheter (CPT code 
51701) provided on August 2, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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 code 51701 
is a column II code to column I code 51720 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for insertion of non-indwelling bladder catheter (CPT code 51701) provided on 
August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BGx Comprehensive Hereditary Cardio Genetic Testing 
provided on January 21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the results of this test will not impact the management of their known cardiovascular 
disease. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. The enrollee does not meet 
criteria. This enrollee has known cardiovascular disease not suspected cardiovascular disease. The results of 
this test will not impact the management of their known cardiovascular disease. Therefore, we decided that the 
Plan does not have to pay for the BGx Comprehensive Hereditary Cardio Genetic Testing provided on January 
21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that you need this service to 
be approved for coverage as soon as possible. The Plan denied your request. The Plan says you must have 
results of a recent clinical evaluation related to your chief complaint or current condition that support the 
requested study. The Plan also says that your records do not show results of a prior study, such as an x-ray or 
ultrasound, that support further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is not medically reasonable and necessary in this 
case. Our physician reviewer found the records show that you recently had a ureteroscopy, and the results of a 
kidney, ureter, and bladder (KUB) ordered by your urologist were not in the records. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 10, 
2022.