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

 
We decided that the Plan does not have to pre-approve a Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that you disagree with the denial and 
request reconsideration for the implantation of a carotid sinus baroreflex system due to heart failure. The Plan 
denied your request. The Plan says the requested device is considered unproven and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator 
implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse 
generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the 
carotid arteries. In August 2019, the FDA approved the system for use in enrollees with refractory heart failure 
who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have 
an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical 
study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in enrollee management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's 
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 a Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device (0266T, C1825).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continuous positive airway pressure (CPAP). 
 
You asked the Plan to pre-approve CPAP. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CPAP is covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CPAP. Our reviewer says that the 
documentation does support that the requested CPAP is medically reasonable and necessary. Our physician 
reviewer found the enrollee is troubled by excessive daytime sleepiness and has diagnoses of hypertension and 
prior atrial fibrillation. Attended polysomnography on April 18, 2023, showed an apnea-hypopnea index (AHI) 
of 3.4 and a respiratory disturbance index (RDI) of 6.2. There was hypoxemia during the study, correctable 
with oxygen at 2 L/min. Either an AHI or an RDI above or equal to 5.0 meets Medicare criteria for a diagnosis 
of obstructive sleep apnea and treatment with CPAP, if there are symptoms or a diagnosis of hypertension. 
Therefore, the enrollee meets criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP have been met. Therefore, we decided that the Plan has to pre-approve 
continuous positive airway pressure (CPAP).  
 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 waive the copayment for an in-network hearing exam provided on 
February 07, 2023. 
 
You asked the Plan to waive the copayment for an in-network hearing exam. You say that you want this copay 
waived. There is a $0 copayment for this service. 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 $15 
copayment for hearing services. 
 
You have been asked to pay a $15 copayment for an in-network hearing exam. This item/service falls within 
the hearing services 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 in-network 
hearing exam provided on February 07, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services and air mileage 
provided on July 21, 2022. You asked the Plan to pay for the ambulance services. You say that the transport was reasonable and medically 
reasonable for the air ambulance service. The Plan denied your request. The Plan says the appeal does not 
support criteria for fixed wing ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 ambulance services. Our reviewer says 
that the fixed wing ambulance transport services were not medically necessary. Our physician reviewer found 
while the transfer for further evaluation was medically necessary and reasonable, it appears that the enrollee 
was stable and could have been transported via a ground ambulance. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance service, conventional air services and air mileage provided on July 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided on August 10, 
2022.  
 
You asked the Plan to pay for the DecisionDx-Melanoma test. You say that this test was ordered by the 
enrollee's treating physician with the intent to use the test results to inform treatment decisions. The Plan 
denied your request. The Plan says the enrollee has tumor stage T1a with no such concern regarding the 
adequacy of microstaging documented.  
 
The Plan follows Medicare rules. Medicare rules say that the criteria in the Medicare Rules section of this letter 
are met.  
 
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 DecisionDx-Melanoma test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that per the National 
Comprehensive Cancer Network (NCCN) Guidelines the use of gene expression profiling (GEP) testing, such 
as with DecisionDx Melanoma, according to specific AJCC-8 melanoma stage (before or after sentinel lymph 
node biopsy (SLNB)) requires further prospective investigation in large, contemporary data sets of unselected 
patients. Prognostic GEP testing to differentiate melanomas at low versus high risk for metastasis should not 
replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I 
melanoma and a higher proportion of false-positive results, GEP testing should not guide clinical decision-
making in this subgroup. On an individual basis, the likelihood of a positive SLNB may be informed by the use 
of multivariable nomograms/risk calculators and ongoing investigation of GEP tests. The above provided 
criteria are not met. The service was not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DecisionDx-Melanoma test have not been met. Therefore, we decided that 
the Plan does not have to pay for the DecisionDx-Melanoma test provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic eye exam (92014) provided on January 26, 
2023. 
 
You asked the Plan to pay for the diagnostic eye exam (92014). You say that the service was medically 
necessary. 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 the diagnostic eye exam 
(92014) provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on January 04, 2023, to 
January 07, 2023. 
 
You asked the Plan to pay for the office visit (99212). You say that the service was medically necessary. 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 the office visit (99212) 
provided on January 04, 2023, to January 07, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need therapy to build strength to come home 
and be able to do daily living. The Plan denied your request. The Plan says the SNF services requested do not 
meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF admission to 
maximize their rehabilitation potential. The Plan denied your request. The Plan says that the enrollee does not 
meet all the requirements for admission to an IRF.  
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollees medical presentation is inherently complex and fragile. The enrollee can definitely 
participate in and benefit from IRF placement per the unanimous consensus of their treating team, with services 
including occupational therapy and physical therapy, and coordination among the various physician specialties 
needed to increase the chance of a good oncological outcome and a sustainable and well-planned return to a 
home setting with any modifications that may be needed. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
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 the AVISE CTD test genetic panel provided on September 
14, 2022.  
 
You asked the Plan to pay for the AVISE CTD test genetic panel. You say that this testing was deemed 
medically necessary by the treating physician The Plan denied your request. The Plan says the AVISE CTD 
test panel is considered experimental and investigational, as it is unproven to alter disease prognosis or 
treatment outcomes. It has not been proven to be superior to alternative tests and measures of disease activity. 
 
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 pay for the AVISE CTD test genetic panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that per the reviewed literature, the AVISE CTD test panel is considered 
experimental and investigational, as it is unproven to alter disease prognosis or treatment outcomes. It is not 
considered a better test to measure disease activity. The review has determined that the items/services at issue 
in this case were not medically reasonable or 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 AVISE CTD test genetic panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the AVISE CTD test genetic panel provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6219) provided on September 14, 2022. 
 
You asked the Plan to pay for the gauze (A6219). You say that the item should be covered. 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 the gauze (A6219) 
provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test identifies treatable causes of pain. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on 
November 01, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care (99309). You say that the service was medically 
necessary. 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 subsequent nursing 
facility care (99309) provided on November 01, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says Durolane is a non-
preferred drug.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane. Our physician reviewer 
found that the enrollee has bilateral knee pain due to osteoarthritis. The Plan requires a trial of Orthovisc, 
Synvisc, Monovisc, or Synvisc-One before they will approve the requested drug. The enrollee has received left 
knee injections with Synvisc and Orthovisc, with good relief in the past. There is no documentation provided 
indicating that the Plans required drugs have been less effective or have had adverse effects for the enrollee.  
The documentation does not support that Durolane is medically reasonable or necessary for the 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on April 21, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory testing. You say that the enrollee was referred to you by another 
provider. The Plan denied your request. The Plan says the referring provider is also OON. 
 
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 Plan's POS benefit only applies to covered routine dental 
services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on April 21, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 01, 2022, to 
December 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the service should be covered. 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 the laboratory services 
provided on December 01, 2022, to December 28, 2022.