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

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation procedure 
(64624) provided on March 23, 2023. 
 
You asked the Plan to pre-approve the genicular nerve radiofrequency ablation procedure. You say that the 
records provided support the need for the services in dispute. The Plan denied your request. The Plan says the 
services in dispute were 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 genicular nerve radiofrequency 
ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has left knee osteoarthritis. Genicular nerve 
radiofrequency ablation is considered experimental and investigational therapy.  It is the subject of ongoing 
clinical trials. 
 
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 genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation 
procedure (64624) provided on March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a SNF stay provided from January 1, 2023, 
to January 20, 2023. 
 
You asked the Plan to reduce the copayment for a SNF stay. You say that the claim was billed and paid as an 
out-of-network provider, but the facility agreed to accept the Plan's amount for payments. 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 $0 
copayment for days 1 to 20, a $196 copayment per day for days 21 to 33, and $0 copayment for additional 
days, up to 100 days for SNF care.  
 
You have been asked to pay a $2,120 copayment for a SNF stay. This total is less than the standard copayment 
for a SNF stay because your maximum out-of-pocket was met with the processing of this claim. This 
item/service falls within the SNF 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 reduce the copayment for a 
SNF stay provided from January 1, 2023, to January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 13, 2023, to March 20, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
copayment applied for the inpatient hospital stay. 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 $390 
copayment per day for days 1 to 5 and $0 copayment for additional days for inpatient hospital care.  
 
 You have been asked to pay a $1,950 copayment for an inpatient hospital stay ($390 per day x 5 days = 
$1,950). 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 an inpatient hospital stay provided from March 13, 2023, to March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart System. 
 
You asked the Plan to pre-approve the Optimizer Smart System. You say that requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says a review of the current medical literature does 
not support the Optimizer Smart System to be reasonable and necessary. This device is considered 
experimental and investigational because it is not identified as widely used and generally accepted as reported 
in nationally recognized peer-reviewed medical literature published in the English language. The efficacy of 
the Optimizer Smart System is still uncertain at this time according to leading authorities and not recommended 
in current guidelines for the treatment of heart failure. More medical research is needed to support this is safe 
and effective for your condition. 
 
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 Optimizer Smart System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Cardiac Contractility Modulation (CCM) device is still a research tool and in 
an investigational phase. None of the professional societies have recommended this device for advance heart 
failure (HF) treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Optimizer Smart System.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy provided on April 24, 2023. 
 
You asked the Plan to pay for group psychotherapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this provider type is not eligible in the Medicare program.  
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for group psychotherapy provided on April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has recurrent congestive 
heart failure. The CardioMEMs device was approved by the Food and Drug Administration (FDA) in 2014. 
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 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
December 5, 2022, to December 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the submitted documentation supports observation care. 
 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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee with chronic atrial fibrillation on Eliquis who presented to the emergency 
department (ED) with lightheadedness, diaphoresis, palpitations lasting 20-30 minutes. The evaluation revealed 
the enrollee was alert and oriented, normal blood pressure, electrocardiogram (ECG) with atrial fibrillation, rate 
controlled, without ischemia, but troponin was elevated. However, troponin was repeated and was determined 
not to be acute coronary syndrome. Based on the stability and low severity of the enrollees presentation and 
acute conditions ruled out, it was not expected that the enrollee would have required hospital services that 
would have likely crossed two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 5, 2022, to  
December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. The 
Plan also says that you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. In addition, this 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 genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on March 16, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 
81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 22, 2022, 
to January 19, 2023, billed with primary diagnosis code T81.89XD. 
 You asked the Plan to pay for the home health services as billed. You say that it is felt that the correct primary 
diagnosis was reported.  The Plan denied your request. The Plan says this home health payment was reduced as 
the primary diagnosis code was not supported.  
 
The Plan follows Medicare rules. Medicare rules say that home health payment groups are assigned a HIPPS 
code that is calculated by combining claims data and OASIS assessment information. 
 
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 home health services as billed. Our 
reviewer says that the documentation does not support the primary diagnosis code. Our physician reviewer 
found diagnosis code T81.89XD is defined as "other complications of procedures, not elsewhere classified, 
subsequent encounter". Provided home health records in this case document the plan of care was to 
"assess/evaluate comorbid conditions including chronic obstructive pulmonary disease, hyperlipidemia, 
hypertension, asthma, coronary artery disease, tobacco dependence, peripheral arterial and vascular disease, 
safe medication management, pain management, and fall prevention" with patient goals "to get stronger again. 
Provided records are inadequate to support T81.89XD as the primary diagnosis for this home health episode of 
care as opposed to Z47.81, encounter for orthopedic aftercare following surgical amputation.  
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from December 22, 2022, to January 
19, 2023, billed with primary diagnosis code T81.89XD.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve wireless capsule endoscopy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee had a dramatic anemia. 
Although an angioectasia was found in the duodenum, he may have more than one angioectasia. If one is found 
more distally, a repeat endoscopy could be completed to prevent further bleeding. The wireless capsule 
endoscopy is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve wireless capsule endoscopy.  
 
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 pre-approve a home health aide. 
 
You asked the Plan to pre-approve the aide services. You say that you are falling, cannot be standing up and 
needs to be in bed all the time. You say that you need help bathing and that you live by yourself. The Plan 
denied your request. The Plan says you would like to request reconsideration of the denied claim and that the 
services requested are medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
  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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation does not specify any care plan in which the services of a professional home health aide would 
be required. Clinical documentation only states that patient has poor balance and abnormal gait, however, does 
not specify any functional impairments or that patient is home bound. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home health aide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0813). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you do not require a powered 
wheelchair to complete mobility related activities of daily living in your home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0813).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation of the genicular nerve 
(64624). 
 
You asked the Plan to pre-approve the radiofrequency ablation of the genicular nerve. You say that you are 
requesting reconsideration because the procedure will give you more flexibility with your family and 
grandchildren. The procedure will give you more range of motion. The Plan denied your request. The Plan says 
a review of the current medical literature does not consider this service to be standard medical treatment for 
your condition. 
 
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 radiofrequency ablation of the genicular 
nerve. Our reviewer says that the requested items/services is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that this procedure is considered experimental therapy. It 
is the subject of ongoing clinical trials. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the genicular nerve have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the radiofrequency ablation of the genicular nerve (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 96413 billed for date of service May 18, 2023. 
 
You asked the Plan to pay for code 96413. You say that this is a payable code. The Plan denied your request. 
The Plan says 96413 is not the appropriate administration code for Simponi. 
 
The Plan must follow Medicare rules. Medicare rules say that the administration of Simponi should not be 
billed using a complex drug administration code. In this case, the code you billed (96413) is to be used only for 
the administration of a complex drug.  Medicare has determined that Simponi is not a complex drug, so a 
different administration code should be used instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 96413 have not been met. Therefore, we decided that the Plan does not have to pay for code 
96413 billed for date of service May 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that if the enrollee is admitted into an 
LTACH they will receive respiratory therapy, telemetry monitoring, intravenous (IV) antibiotics, physical and 
occupational therapy, these needs cannot be met at a lower level of care. The Plan denied your request. The 
Plan says the enrollee's continued care needs include completing evaluation for your infection, IV antibiotics 
and ventilatory support. The Plan says the enrollee can receive this care in the current acute care 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 that per the neurology note, the enrollee has a poor prognosis. Additionally, head 
computed tomography (CT) shows anoxic brain injury and the enrollee remains unresponsive. Documentation 
does support that the enrollee is expected to improve or benefit from care at an LTACH. 
 
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 the LTACH services.