Persius/hicric huggingface dataset:
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 needs to return to baseline function. The 
Plan denied your request. The Plan says the enrollee's records do not show that you have complex rehabilitation 
needs that require frequent evaluation by a rehabilitation doctor and an intensive team for 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 28, 2022. 
 
You asked the Plan to pay for the physical therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the health Plan requires utilization of network providers when possible 
and available and requires authorization for certain services. No medical necessity for an out-of-network 
provider, such as an urgent or emergency situation, has been documented.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 4, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says you received 
services from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on February 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a tertiary level of care neurologist. 
 
You asked the Plan to pre-approve an office visit with a tertiary level of care neurologist. You say that you 
have been a patient of this provider for over seven years, and you are requesting coverage to see this provider 
in the interest of continuity of care. The Plan denied your request. The Plan says the requested office visit with 
a tertiary level of care neurologist 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 an office visit with a tertiary level of 
care neurologist. Our reviewer says that the requested office visit with a tertiary level of care neurologist is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the most recent 
consult notes provided for review otherwise indicated that your multiple sclerosis (MS) has been stable on Avonex. Given your disease stability while on a disease modifying therapy, your care could be provided by an 
in-network neurologist. Referral to a tertiary provider at this juncture would otherwise not be a service 
"Furnished in a setting appropriate to the patient's medical needs and condition". Nor would it be "One that 
meets, but does not exceed, the patient's medical need".  Rather a tertiary consult for stable MS would exceed 
your needs. Therefore, this service would not be 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 an office visit with a tertiary level of care neurologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an office visit with a tertiary level of care 
neurologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system (02667, C1825). 
 
You asked the Plan to pre-approve the Barostim NEO system . You say that you ask that the denial be 
reviewed, and the request be approved. The Plan denied your request. The Plan says medical studies have not 
proven that this procedure is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical value and effectiveness of the Barostim Neo System in 
the setting of congestive heart failure have not been demonstrated in the peer-reviewed literature.  Based on 
this information, we decided that Medicare rules for coverage of the Barostim Neo system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Barostim Neo system (02667, C1825).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 16, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says services from non-par providers are not covered under an HMO plan unless 
preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the noninvasive coronary fractional flow reserve 
derived from coronary computed tomography (CT) angiography (FFRct) (0503T) provided on March 31, 2022.  
 
You asked the Plan to pre-approve the FFRct testing. You say that the service in this case was medically 
necessary. The Plan denied your request. The Plan says the service was 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 FFRct testing. Our reviewer says 
that the FFRct was not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that the enrollee has an increased coronary calcium score but no 
cardiac symptoms. The reviewer found that it cannot be established that the enrollee is a candidate for FFRct, 
per current guidelines. Therefore, the reviewer found that the requested FFRct was 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 FFRct testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the noninvasive coronary fractional flow reserve derived from coronary computed 
tomography (CT) angiography (FFRct) (0503T) provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve XomeDX Plus genetic testing for mitochondrial disease 
(81460). 
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the requested service is not a 
covered benefit and is considered 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve XomeDX Plus genetic testing for mitochondrial disease (81460).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulation (PNS) system 
(64555). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that the enrollee has asked you to appeal 
this decision as this pain has worsened over the past few months and would like to have it addressed. The Plan 
denied your request. The Plan says the SPINT PNS is still being studied and has insufficient medical literature 
to see if this treatment is as good or better than standard treatment for chronic pain.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is insufficient medical literature to support the use of the Sprint 
PNS system for chronic back pain. Current peer-reviewed data does not support PNS for fibromyalgia, 
phantom limb pain, diffuse polyneuropathy, nociceptive pain in trunk or lower back, or angina pectoris. The 
enrollee is not enrolled in a Medicare-approved clinical study evaluating use of the Sprint PNS system.  Based on this information, we decided that Medicare rules for coverage of the Sprint PNS system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulation (PNS) 
system (64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
December 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed as a single unit of service. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel rendered on December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the enrollee still needs home care. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the submitted 
records do not document that home health nursing services are required for the enrollee's Foley catheter care. 
Only wound care was documented by the nurse. The enrollee is seeing a provider in an office setting for 
catheter care, and the enrollees wounds no longer require skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve a blood pressure monitor. You say that your doctor stated that it is very 
important to check your blood pressure all the time and the standard blood pressure machines do not work for 
you. The Plan denied your request. The Plan says that that you are not on home dialysis. 
 
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 blood pressure monitor. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that you will benefit from home blood pressure monitoring to avoid hypotension. 
 
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 blood pressure monitor have been met. Therefore, we decided that the Plan 
has to pre-approve an automatic blood pressure monitor (A4670).  
 
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: Partially Favorable

 
We decided that the Plan has to waive the copayments for the specialist office provided on January 17, 2023. 
We also decided that the Plan does not have to waive the copayments for the specialist office visit provided on 
February 14, 2023. You asked the Plan to waive the copayments for the specialist office visits provided on January 17, 2023, and 
February 14, 2023. You say that these should be considered post-op appointments and have no copayment. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayments for the specialist office provided on January 17, 
2023.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide an Explanation of benefits (EOB) for date of service 
January 17, 2023. Without a valid EOB we are unable to verify that the cost sharing was applied correctly. 
Therefore, we decided that the Plan has to waive the copayment for the specialist office visit provided on 
January 17, 2023.  
 
We also decided that the Plan does not have to waive the copayments for the specialist office visit 
provided on February 14, 2023. 
 
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 $30 
copayment for each specialist office visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit provided on February 14, 2023. This 
item/service falls within the physician/practitioner services benefit category. 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 specialist office visit provided on February 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar laminectomy, spinal fusion, including any 
associated procedures, implants or supplemental bone products (20930, 20936, 22614, 22633, 22612, 22842, 
22853 and 63052) and the inpatient hospital care. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has a longstanding history of back 
pain, which has diminished the enrollee's quality of life. You state the enrollee has had zero improvement with 
conservative care and the enrollee has decreased functions of the enrollee's daily living activities. The Plan 
denied your request. The Plan says a review was not completed timely. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for codes: 22633 and 22612, the medical records provided do not meet the requirements listed 
in the LCD L37848 for Medicare coverage. For codes: 20930, 20936, 22614, 22842, 22842, 22853, 63052, 
these services are not medically necessary. The main procedure is not supported. Therefore, 20930, 20936, 
22614, 22842, 22842, 22853, and 63052 are not medically necessary based on Medicare criteria. Furthermore, 
the record does not show that the physician reasonably expects that the enrollee's necessary hospital care will 
span 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar laminectomy, spinal fusion, including any associated procedures, implants or 
supplemental bone products (20930, 20936, 22614, 22633, 22612, 22842, 22853 and 63052) and the inpatient 
hospital care.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20680. We decided that the Plan does not have to pay for 23430.  
 
You asked the Plan to pay for procedure codes 20680 and 23430 rendered on September 7, 2022.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 20680.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of CPT 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)." 
 
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 for CPT 20680. Our reviewer says that the records do 
support CPT 20680 as a separate and distinct procedure from CPT 23472. The procedure details cite two 
anchors were removed from the humerus from the previous rotator cuff repair. This was performed prior to 
continuing on with the total shoulder replacement. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
20680.  
 
We also decided that the Plan does not have to pay for 23430. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of CPT 23430 is "Tenodesis of long tendon of biceps." 
 
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 for CPT 23430. Our reviewer says that the records do 
not support CPT 23430 as a separate and distinct procedure from CPT 23472. The procedure details cite the 
superior 1cm of the pectoralis tendon into the biceps groove was released. The biceps was tenodesed. The 
biceps tendon was cut proximally to the tenodesis. However, this was part of the overall procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 23430 have not been met. Therefore, we decided that the Plan does not have to 
pay for 23430. 
 
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.