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

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS device is 
medically necessary. The Plan denied your request. The Plan says the CardioMEMS device 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 the CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary. Our 
physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert 
opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93308, 93321, and 93325 billed for date of 
service April 27, 2023. You asked the Plan to pay for procedure codes 93308, 93321, and 93325. You say that medical records were 
provided for review. The Plan denied your request. The Plan says payment for codes 93308, 93321, and 93325 
are bundled into payment for code 33361. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that codes 93308, 93321, and 93325 are column II codes to column I code 
33361. The codes at issue have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 93308, 93321, and 93325 billed for date of service April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes and foot inserts.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes and foot inserts.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 laboratory services 
provided on June 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15630 billed for date of service July 14, 
2023. 
 
You asked the Plan to pay for procedure code 15630. You say that this service is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says the service at issue was not billed with 
the required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 14041 
provided on June 6, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 15630 billed for 
date of service July 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on August 3, 2023, billed with 
codes 87150, 87481, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a 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 a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on August 3, 2023, billed with codes 87150, 87481, 87641, 87653, 87798 and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressing supplies coded as A6222 billed on July 
3, 2023. 
 
You asked the Plan to pay for the wound dressing supplies. You say that the wound dressing supplies should be 
paid as billed because they were not incident to any other procedure with which payment could be bundled. 
The Plan denied your request. The Plan says the wound dressing supplies are denied because A6222 has a 
status indicator of P, meaning payment is always bundled into payment for other services not specified and no 
separate payment is made. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 Records show that the wound dressing supplies were used in a SNF. Therefore, we decided that the Plan does 
not have to pay for the wound dressing supplies coded as A6222 billed on July 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the medical records 
submitted do not include a physician order or laboratory requisition for the billed test. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has an amputated foot and requires IRF 
services to learn how to function with his new life style. The Plan denied your request. The Plan says the 
request is not medically necessary.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a wheelchair ramp for inside the home. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you need the ramp so you can maneuver 
around your home which has uneven flooring. The Plan denied your request. The Plan says that the requested 
item is not a covered benefit. 
 
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 a wheelchair ramp. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a power wheelchair that was provided by the Plan. You are unable to maneuver 
around your home that has uneven flooring. You never received a home assessment for the power wheelchair 
that was provided by the Plan. The documentation shows that the requested ramp for inside the home is 
medically reasonable and necessary for you to be able to utilize the wheelchair you currently have. 
 
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 wheelchair ramp have been met. Therefore, we decided that the Plan has to 
pre-approve a wheelchair ramp for inside the home.  
 
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 urinary tract infection (UTI) panel (87481) provided on 
May 11, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this 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 pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex polymerase chain reaction (PCR) urinary tract infection panel tests. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urinary tract infection (UTI) panel (87481) provided on May 11, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a percutaneous transluminal angioplasty (PTA) (37226). 
 
You asked the Plan to pre-approve a percutaneous transluminal angioplasty (PTA). You say that the enrollee 
could be at risk for losing a limb. The Plan denied your request. The Plan says that your request is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when the criteria listed in the 
Medicare rules section 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 pre-approve a percutaneous transluminal angioplasty 
(PTA). Our reviewer says that the documentation meets coverage criteria and supports the medical necessity of 
the treatments in question. Our physician reviewer found the enrollee has an ulceration of the tip of their right 
third finger and a second, superficial lesion of the back of the fifth finger. These ulcers are in the setting of a 
patent right brachiocephalic arteriovenous (AV) fistula. As the digital ulceration represents potentially limb 
threatening ischemia, the plan for angiography and possible intervention meets coverage criteria and is both 
reasonable and medically necessary. It is not possible to know exactly which intervention code will be used 
until the angiogram is performed. 
 
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 percutaneous transluminal angioplasty (PTA) have been met. Therefore, we 
decided that the Plan has to pre-approve a percutaneous transluminal angioplasty (PTA) (37226).  
 
 
 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: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot come back and forth to 
rehabilitation, and an inpatient 14 day stay will provide dialysis as well. The Plan denied your request. The 
Plan says the enrollee's condition does not meet all of the requirements for inpatient rehabilitation admission. 
The Plan says services may be provided at a lower level of care.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient services provided from October 11, 2022, to January 9, 
2023. 
 
You asked the Plan to pay for the outpatient services. You say that you do not have another health insurance. 
You also say that you received a bill from your provider. The Plan denied your request. The Plan says that 
payment cannot be made as you have other insurance coverage that is primary. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the outpatient services provided from October 11, 2022, to 
January 9, 2023.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zoledronic acid (Reclast) injection (J3489). 
 You asked the Plan to pre-approve the medication. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee 
meets the criteria. 
 
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 the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires a trial of drug oral bisphosphonate and diagnosis of osteoporosis before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is 
no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or 
likely have adverse effects 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zoledronic acid (Reclast) injection (J3489).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 13, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that this was performed in good faith. The Plan 
denied your request. The Plan says coverage excludes services related to and required as a result of services 
which are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that treatments for obesity alone remain non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. The records clearly support that the purpose of the 
service in this case was to discuss weight loss options. Therefore, we decided that the Plan does not have to pay 
for the office visit provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83210 billed for date of service May 19, 
2023. 
 You asked the Plan to pay for procedure code 83210. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 83210 is bundled into payment for code 80069. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83210 
is a column II code to column I code 80069. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83210 billed for date of service May 19, 2023.