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

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF system (CPT code(s): C2624 and 
33289). 
 
You asked the Plan to pre-approve the CardioMEMS HF system. You say that the services are necessary. The 
Plan denied your request. The Plan says the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. The Plan states there is no indication that you are enrolled in a clinical trial 
of the device. 
 
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 the 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 your management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in your 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 (CPT code(s): C2624 and 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3020) provided December 7, 2021 to 
December 22, 2021. 
 
You asked the Plan to pay for the foot orthotics. You say that the shoe inserts were medically necessary. The 
Plan denied your request. The Plan says the provider is not registered with Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider that 
does not participate in Medicare. Therefore, we decided that the Plan does not have to pay for foot orthotics 
(L3020) provided December 7, 2021 to December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, thorax, low dose for lung cancer screening, 
without contrast material(s) (CPT code 71271). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says there is no evidence to support the request for the CT scan of the chest for lung cancer 
screening. 
 
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 CT scan. Our physician reviewer 
found the review indicates that the guidelines state if previous advanced imaging within the past three (3) years, showed no abnormalities, then there is no indication of continued imaging. The enrollee's last three 
imaging reports were reviewed and showed no abnormalities or adenopathy. Therefore, there is no evidence to 
support the request for the CT scan of the chest for lung cancer screening. The review has determined that the 
medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT scan, thorax, low dose for lung cancer screening, without contrast material(s) (CPT 
code 71271).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99223) provided on May 18, 2021. 
 
You asked the Plan to pay for initial hospital care (99223). You say that you are resubmitting the claim with 
documents to support CPT code 99223 and the claim should be reviewed for payment. The Plan denied your 
request and upheld the denial. 
 
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 Plan has not forwarded any evidence or rationale to support 
their denial of this claim. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for initial hospital care (99223) provided on May 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of low back pain have not been demonstrated in the peer-reviewed literature. The Plan states more research is 
needed to show safety and efficacy of the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental for back pain at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) 
for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or 
foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, 
unilateral or bilateral; lumbar (CPT code 0275T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the proposed surgery is not considered investigational, however 
additional information is necessary to determine medical necessity. 
 
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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation demonstrates subjective and objective deficits that are 
corroborated by imaging studies. Trial and failure of conservative treatment modalities have been documented. 
There is current evidence-based medical literature support for the use of this procedure for the treatment of 
spinal stenosis (including as compared to lumbar epidural steroid injection.) The enrollee presents with clear 
spinal stenosis exhibiting neurogenic claudication. Therefore, the requested percutaneous 
laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without 
ligamentous resection, discectomy, facetectomy, and/or foraminotomy), any method, under indirect image 
guidance (e.g., fluoroscopic, CT) single or multiple levels, unilateral or bilateral; lumbar (CPT 0275T), in this 
case, is medically reasonable and 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 service have been met. Therefore, we decided that the Plan has to pre-
approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, 
(with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under 
indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT 
code 0275T).  
 
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 25 fractions of intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this is needed to help ensure better target coverage 
when meeting dose constraints. The Plan denied your request. The Plan says that the denial of authorization for 
this service is correct, because intensity modulated radiation therapy (IMRT) is not medically necessary. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a useful tool available to radiation oncologists to potentially reduce toxicity and 
improve dose distribution in select patients when the dosimetry warrants its use. For this enrollee, with a 
complex treatment field and prior radiation, the improvement in the IMRT versus standard plan with respect to 
lung dose exposure is plausible. IMRT would be furnished in accordance with accepted standards 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
25 fractions of intensity modulated radiation therapy (IMRT).  
 
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 the home health services provided to the enrollee from 
September 16, 2021, to October 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP 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 record 
indicates that the RAP was not submitted within 5 days of the start of services. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from September 16, 2021, to 
October 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on September 
10, 2021. 
 
You asked the Plan to pay for home health services. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on 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 claim was not submitted with the required occurrence code. Therefore, we decided that the Plan does not have to pay 
for home health services provided to the enrollee on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on December 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses provided by an OON provider. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not a 
network optical provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the provider is a network optical provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyeglasses were purchased from an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on 
December 21, 2021, by an out-of-network (OON) provider.  
 
Your complaint about the Plan providing incorrect information 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 16, 2021, to June 
17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that additional payment should be made. 
The Plan denied your request. The Plan says that the provided documentation does not support that inpatient 
level of care was provided. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician 
reviewer found although the provided documentation indicates that the enrollee clinically improved and was 
able to be discharged in a time period of less than 2 midnights, it was medically reasonable to expect that care 
would span two midnights at the time of admission. Therefore, the reviewer found that the inpatient admission 
was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 16, 2021, to June 17, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear warranty (V2797), provided on December 5, 
2021. 
 You asked the Plan to pay for the eyewear warranty. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 Benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses at a network optical provider . 
 
We looked at the file and the Plan's rules. Warranties are not covered services under Medicare. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear warranty have been met. Therefore, 
we decided that the Plan does not have to pay for the eyewear warranty (V2797), provided on December 5, 
2021.
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 the requested services. You say that the enrollee had significant 
improvement of his symptoms. The Plan denied your request. The Plan says the enrollee has not had three 
months of pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that the enrollee underwent an epidural steroid 
injection on March 29, 2022. A repeat injection is covered when there is sustained pain relief for at least three 
months. Based on this information, we decided that Medicare rules for coverage of the requested services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of code 99203 billed for date of service May 21, 
2021. 
 You asked the Plan to pay for two units of code 99203. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says only one unit of this code is payable per day. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99203 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of two units 
of code 99203 have not been met. Therefore, we decided that the Plan does not have to pay for two units of 
code 99203 billed for date of service May 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 11, 
2021. 
 
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 the submitted records do not support the billing of code 99284. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is Level 4 emergency department visit for 
evaluation and management of patient with problem of high severity, including detailed history and physical 
examination, and medical decision-making of moderate complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that the submitted records 
do not support the billing of code 99284. Our reviewer found the submitted emergency department (ED) documentation does not support the 99284 level of services. The documentation supports an extended problem-
focused visit, comprehensive, and medical decision making of moderate complexity. 
 
We looked at this coder'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 emergency room (ER) services rendered on April 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0651, E0667, 
E0673). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the prevention of deep vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0651, E0667, E0673).