Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a diagnostic ultrasound (CPT 76981) provided on September 21, 2022. 
 
You asked the Plan to pay for the diagnostic ultrasound (CPT 76981). You say that the diagnostic ultrasound 
was medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness 
of screening liver elastography in the setting of metabolic syndrome have not been demonstrated in the peer-
reviewed literature. 
 
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 pay for the diagnostic ultrasound (CPT 76981). Our 
reviewer says that the diagnostic ultrasound is considered medically reasonable and necessary in this case. Our 
physician reviewer found that metabolic syndrome has been linked to liver steatosis and chronic liver 
disease. Ultrasound elastography has been shown in the literature to be useful in the screening of these patients 
for developing chronic liver disease. The elastography ultrasound exam of September 21, 2022, was 
appropriate and should be reimbursed. 
 
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 diagnostic ultrasound (CPT 76981) have been met. Therefore, we decided 
that the Plan has to pay for a diagnostic ultrasound (CPT 76981) provided on September 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing services provided on October 06, 
2022. 
 
You asked the Plan to pay for laboratory drug testing services. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory drug testing 
services provided on October 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 
13, 2022, to October 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $1,700 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,700 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provided on October 13, 2022, to October 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 04, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 $75 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $75 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/ultrasound 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 an 
ultrasound provided on November 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 skin substitute. 
 
You asked the Plan to pre-approve Kerecis Omega3 skin substitute. You say that the documentation provided 
supports the need for the services in dispute. You say that the enrollee has a biopsy proven Basal Cell 
Carcinoma, nodular located on his left ala. You say that, due to the wound size and location, you are requesting 
authorization for the use of Kerecis Omega3 skin substitute to assist and promote proper wound healing. You 
say that the product is approved by the Food and Drug Administration (FDA) for use in coordination with 
surgical procedures to assist in wound healing. You say that the product is also approved and paid for by 
Medicare as it meets their guidelines of medical necessity. The Plan denied your request. The Plan says they 
did not receive any records showing that the enrollee has a wound on their nose that has failed thirty days of 
standard wound management with measurements. The Plan says that literature shows that Kerecis is considered 
to be experimental and investigational for this type of 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 Kerecis Omega3 skin substitute. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of nodular Basal cell carcinoma of skin of nose. The 
enrollee underwent Mohs micrographic surgery on the left nasal ala on February 27, 2023. Kerecis was placed 
in the defect which measured 1.4 x 1.3 centimeters (cm) at that time. Another application of Kerecis has been 
requested. The case file does not contain updated clinical records supporting that Kerecis Omega3 skin 
substitute is medically reasonable and necessary for the enrollee 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 Kerecis Omega3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Kerecis Omega3 skin substitute.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollee wasn't enrolled in hospice on the date of 
service and ask the plan to submit payment. The Plan denied your request. The Plan says services should be 
billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on July 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for an office visit provided on 
July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Venaseal varicose vein procedure (36482, 36483) 
 
You asked the Plan to pre-approve the surgical procedure. You say that please reconsider approving this 
procedure so that you may prevent deterioration of the enrollee's physical health in the near future. The Plan 
denied your request. The Plan says the Venaseal varicose vein procedure is considered experimental or 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support the medical necessity of the procedures in 
question. It is documented that the enrollees symptoms are not impacting their ability to perform daily 
activities or work. It is documented that the enrollee has not yet trialed conservative efforts such as 
compression stockings. It also seems, from the letter, that the enrollee is most concerned about the continued 
loss of feeling in their legs and feet, but it is not at all clear that these symptoms are related to the varicose 
veins. There is no assessment in the medical record of how the enrollees symptoms are related to the varicose veins. More importantly, there is no documentation in the medical record of what the treatment plan is. 
Therefore, unable to overturn the health Plans determination. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Venaseal varicose vein procedure (36482, 36483)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interlaminar/interspinous stabilization device 
(22867). 
 
You asked the Plan to pre-approve the Coflex device. You say that this is medically necessary due to the 
enrollee's diagnosis and failure to adequately respond to multiple non-surgical treatments. The Plan denied your 
request. The Plan says there is a lack of evidence to support the Coflex interlaminar/interspinous device as a 
safe and effective treatment for lumbar spinal stenosis compared to standard methods of management. 
 
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 Coflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The Coflex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex interlaminar/interspinous stabilization device (22867).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the records provided support the need 
for the requested device. The Plan denied your request. The Plan says that the requested device is not needed in 
accordance with the Food and Drug Administration (FDA) approved label for devices as part of, or following, 
an FDA approved study. 
 
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. Medicare rules also say that 
CMS covers leadless pacemakers through CED.  
 
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 leadless pacemaker. Our reviewer 
says that a leadless pacemaker is considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical appropriateness and necessity of implanting a leadless pacemaker, 
instead of a traditional pacemaker with an intravascular lead, in an enrollee on chronic hemodialysis who is felt 
to require a permanent pacemaker owing to symptomatic bradycardia. The advantage of the leadless pacemaker 
is avoidance of an intravascular lead, while the limitation is the inability to allow pacing in the atrium, as well 
as the inability to remove and replace the generator at the time of battery depletion, roughly every 10 years, 
with a need to place a new unit at time of battery depletion. However, the enrollee's advanced age makes him a 
suitable candidate, as opposed to a young person, for which a leadless pacemaker would not be appropriate. In 
addition, the absence of intravascular leads reduces the enhanced risk of infection and vascular complications 
owing to chronic hemodialysis. Recent guidelines are consistent with the appropriateness of selecting a 
leadless, as opposed to a traditional, pacemaker. This selection should be looked upon as being at the discretion 
of the treating physician. Use of a leadless pacemaker would be considered medically appropriate and 
reasonable in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. CMS has an ongoing Micra CED study that 
was approved on March 9, 2017. Medicare beneficiaries implanted with a Micra AV leadless pacemaker on or 
after this study start date will be included in the study. Based on this information, we decided that Medicare 
rules for coverage of a leadless pacemaker have been met. Therefore, we decided that the Plan has to pre-
approve a leadless pacemaker.  
 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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for the diabetic shoe inserts provided on November 8, 
2022. We decided that the Plan does not have to waive the copayments for the diabetic shoes provided on 
November 8, 2022.  You asked the Plan to waive the copayments for the diabetic shoes and inserts. You say that you were 
misquoted for the items and should not have to pay the copayment. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the copayments for the diabetic shoe inserts provided on 
November 8, 2022.  
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE).  
 
You have been asked to pay a $30 copayment for the diabetic shoe inserts, equaling a total of $60. The Plan did 
not provide documentation showing the number of units purchased. Without this information we are unable to 
determine if the cost share was applied correctly. Therefore, we decided that the Plan has to waive the 
copayments for the diabetic shoe inserts provided on November 8, 2022.  
 
We also decided that the Plan does not have to waive the copayments for the diabetic shoes provided on 
November 8, 2022. 
 
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 $10 
copayment for diabetic shoes and inserts.  
 
You have been asked to pay a $10 copayment for each diabetic shoe. These items/services fall within the 
diabetic services and supplies 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 copayments for the diabetic 
shoes provided on November 8, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the deductible for the inpatient hospital stay. We decided that the Plan 
does not have to waive the deductible for the inpatient hospital stay.  
 You asked the Plan to waive the deductible for the inpatient hospital stay provided by an in-network provider 
from October 29, 2022, to November 8, 2022. You say that you already met your deductible. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the deductible for the inpatient hospital stay.  
 
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 says that you must pay the full cost for 
most covered services until you have paid the $1484 Medicare Part A deductible, and the deductible applies to 
in and out-of-network inpatient hospital care services. The Plan says you must pay a $1556 Medicare Part A 
deductible for the inpatient hospital care services. Based on the Plan contract, however, you cannot be asked to 
pay more than a $1484 Part A deductible for the inpatient hospital stay. Therefore, we decided that the Plan has 
to reduce the Part A deductible for the inpatient hospital stay.  
 
We also decided that the Plan does not have to waive the deductible for the inpatient hospital stay. 
 
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 $1484 
Medicare Part A deductible, which applies to in and out-of-network inpatient hospital services. 
 
The inpatient hospital stay falls within the inpatient hospital care benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1484 Medicare Part A deductible, which 
applies to in and out-of-network inpatient hospital care. This cost sharing is a contractual obligation that had 
not been met at the time the inpatient hospital stay was provided from October 29, 2022, to November 8, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the inpatient hospital stay. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that the enrollee is a new patient. You 
also say that the enrollee would have much better control if she could check sugar levels regularly. The Plan 
denied your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Freestyle Libre 2 sensor have been 
met. Specifically, the plan received additional documentation but the record received does not provide enough 
information to determine whether the enrollee meets Medicare criteria for a CGM.  Supporting medical records should be sent to the Plan to show why the enrollee needs a CGM. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that this is needed as BiPAP does not meet 
her needs. The Plan denied your request. The Plan says there are BiPAP devices available able to provide the 
level of support needed in this case. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ventilator. Our reviewer 
says that the requested ventilator is not shown to be medically reasonable and necessary. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (iVAPS) mode with auto-titration (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide 
positive airway pressure or BiPAP therapy for conditions described in this policy will be denied as not 
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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.