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

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289). 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 enrollees 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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Travatan Z. 
 
You asked the Plan to pre-approve Travatan Z. You say that the enrollee has tried the generic Travatan Z 
0.004% and has had adverse reaction. You also say that the enrollee was doing well on the brand, and is 
requesting to get it approved. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Travatan Z.  
 
Benefits for Travatan Z may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 meets the full criteria for an inpatient 
acute rehabilitation stay. The Plan denied your request. The Plan says the IRF services requested do not meet 
the requirements for approval. 
 
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. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel 
provided on April 7, 2022, billed with codes 87486, 87496, 87498, 87502, 87532 ,87541, 87581, 87634, 87640 
and 87798. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this test was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. These panels are effectively a one size fits all diagnostic 
approach, and do not meet Medicares reasonable and necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a multiplex PCR respiratory viral panel 
service, one panel should be reported with an appropriate CPT code and one unit of service. In addition, the 
rules say that tests that include more than 5 viral pathogens are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory PCR panel have not been met. Specifically, this panel was reported with multiple 
codes/units of service and covers more than 5 viral pathogens. Therefore, we decided that the Plan does not 
have to pay for the respiratory PCR (polymerase chain reaction) panel provided on April 7, 2022, billed with 
codes 87486, 87496, 87498, 87502, 87532 ,87541, 87581, 87634, 87640 and 87798.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve service dog support (S5199). 
 
You asked the Plan to pre-approve service dog support. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that you do not meet the criteria for coverage. 
 
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 has not forwarded a valid denial. You have provided all the required 
documentation for this request, including supporting documentation identifying you as the owner and recipient 
who requires the use of a service dog. Therefore, we decided that the Plan has to pre-approve service dog 
support (S5199).  
 
 
 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Monovisc. Our reviewer says that 
Monovisc is medically necessary, safe, and effective for the enrollee. Our physician reviewer found that the 
enrollee has bilateral knee pain due to bilateral osteoarthritis of the knee and there is x-ray evidence of 
progressing tricompartmental degenerative changes. She has been treated with medications, physical therapy, 
corticosteroid injections and previous viscosupplementation therapy with Synvisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have been met. Therefore, we decided that the Plan has to pre-
approve Monovisc (J7327).  
 
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 pay for the discharge services (99239) provided on November 14, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 code 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge management services were provided on the date of service in question. 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 discharge services (99239) provided on 
November 14, 2022.
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 you are requesting an expedited appeal stating the 
enrollee meets the full criteria for an IRF stay. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for bilateral knee replacement surgery. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for an ankle fracture and was discharged to skilled nursing on April 20th, 2023 and has 
been subsequently discharged home. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the arthrocentesis provided on March 30, 
2023. 
 
You asked the Plan to waive the deductible for the arthrocentesis. You say that you should not have to pay for a 
second arthrocentesis when it was not done correctly the first time. 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. Your 
contract with the Plan says that there is a $525 deductible which applies to the arthrocentesis.  
 
 
 
 You have been asked to pay $255.38 towards your deductible for the arthrocentesis. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient surgery including services provided at 
hospital outpatient facilities benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $525 deductible which applies to outpatient surgery including services provided at 
hospital outpatient facilities. This cost sharing is a contractual obligation that had not been met at the time the 
arthrocentesis was received on March 30, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the arthrocentesis provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the MyoPro device is medically necessary. 
The Plan denied your request. The Plan says there is not enough medical evidence that shows the MyoPro is 
reasonable and necessary to improve the function of the enrollee's right arm. This device is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in order to be considered medically necessary, a service cannot be investigational or 
experimental and must be ordered by qualified personnel and be appropriate to the enrollee's medical needs and 
condition. Additionally, there must be an appropriate duration and frequency that is considered appropriate for 
the service. In this case, the requested device is used for the upper extremity. It is an arm brace that is 
motorized and can help an individual with upper extremity weakness to move their arm and hand. The 
requested device has not been shown to be superior to other standard treatments for the medical condition. The 
studies do not indicate the MyoPro brace improves an enrollee's function or general health. The requested 
device is not 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 a MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), fluid 
stance extension (L5848), microprocessor control feature (L5856), flexible protective outer surface covering 
system (L5964), endoskeletal ankle foot system (L5973), axial rotation unit (L5984), stance flexion feature 
(L5845), and knee extension assist (L5850). 
 
You asked the Plan to pre-approve the prosthetic. You say that you need the foot and ankle attachment for the 
prosthetic leg because without it you cannot be active. You also say that it is an important part of your daily 
living and quality of life. The Plan denied your request. The Plan says the microprocessor knee and foot, and 
extra cover exceed your needs and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 prosthetic. Our reviewer says that 
this request is not medically necessary. Our physician reviewer found there are a variety of knee prostheses for 
a K3 walker. The microprocessor knee has been requested to increase ambulation distance. Our reviewer found 
that the microprocessor knee is not necessary to simply increase walking distance. Our physician reviewer also 
found that you are not functioning at a high level or performing activities at a level requiring a microprocessor 
knee. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a fluid swing and stance phase control (L5828), fluid stance extension (L5848), 
microprocessor control feature (L5856), flexible protective outer surface covering system (L5964), 
endoskeletal ankle foot system (L5973), axial rotation unit (L5984), stance flexion feature (L5845), and knee 
extension assist (L5850).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93244) provided on September 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 93244 is not supported in the medical record. Specifically, code 93244 has 
a status indicator M on the outpatient prospective payment system (OPPS). As such, this code is not billable 
and payable under OPPS. 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 services (93244) 
provided on September 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on July 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the claim was billed with primary 
diagnosis code G32.81. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 emergency 
services provided on July 9, 2022.