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

 
We decided that the Plan does not have to pre-approve an OptiMesh cage. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness in spine fusion surgery has not been demonstrated.  
 
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 requested services. Our physician 
reviewer found that the requested OptiMesh cage is experimental. More research is needed to show its safety 
and efficacy. A structural allograft is the standard of care. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an OptiMesh cage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (Q3014) provided on November 28, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
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 Q3014 is telehealth originating site facility fee. 
 
We find that CPT code Q3014 is not supported in the medical record. Specifically, per Medcare Claims 
Processing Manual, Chapter 12, Section 190.5, this code can only be paid for Place of Service 11- Office. The 
claim was not billed with place of service 11. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (Q3014) provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital from 
September 2, 2022, to September 8, 2022. 
 
You asked the Plan to pay for the medication. 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 pay for self-administered drugs provided 
in the hospital from September 2, 2022, to September 8, 2022.  
 
Benefits for the medication 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve wireless capsule endoscopy. 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 wireless capsule endoscopy is covered when certain 
criteria 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 wireless capsule endoscopy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the wireless capsule endoscopy at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for you. Provided records in this case do not 
document any upper and lower endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) 
and colonoscopy) that have failed to identify a bleeding source or any of the other covered indications for the 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wireless capsule endoscopy (91110).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 82172, 82306, 82533, 
82607, 82627, 82728, 82747, 83036, 83090, 83520,83540, 83615, 83698,83735, 83970, 84270, 84305, 84439, 
84443, 84466, 84481, 84550, 86431, 80053, 80061 and 85025. We decided that the Plan does not have to pay 
for the services described by procedure code(s) 83550.  
 
You asked the Plan to pay for laboratory services provided on June 29, 2022. You say that these services were 
necessary and are supported in the medical record. The Plan says that the payment for code 83550 is included 
in the payment for code 84466. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 82172, 82306, 82533, 
82607, 82627, 82728, 82747, 83036, 83090, 83520,83540, 83615, 83698,83735, 83970, 84270, 84305, 84439, 
84443, 84466, 84481, 84550, 86431, 80053, 80061 and 85025.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 82172, 82306, 82533, 82607, 
82627, 82728, 82747, 83036, 83090, 83520,83540, 83615, 83698,83735, 83970, 84270, 84305, 84439, 84443, 
84466, 84481, 84550, 86431, 80053, 80061 and 85025.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83550. 
 
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 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 83550. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377).

You asked the Plan to pre-approve the upgraded electronics. You say that currently no manufacturer allows more than one switch or toggle to control a seating function, therefore if two or more seating functions are needed operation through the joystick is required. The Plan denied your request. The Plan says the notes do not show a medical need to control the power options through the joystick.

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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not medically necessary as the enrollee is able to use their upper extremities and can operate and control the power options using the switches that are included in the basic wheelchair.

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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from January 29, 2021, to February 26, 
2021. 
 
You asked the Plan to pay for home health services. You say that you have provided documents to support the 
services rendered. The Plan denied your request. The Plan says that rules for payment for home health services 
have not been met. 
 
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. Specifically, the Plan's denial states that properly signed documentation, such as 
a home health plan of care, have not been provided in this case. The case record supports that signed, dated 
documents were provided at appeal. The Plan has not provided any alternative rationales for denial. It is the 
Plan's responsibility to support its denial with evidence. In this case, the Plan's denial has not been supported, 
so we must find in your favor. Therefore, we decided that the Plan has to pay for home health services provided 
from January 29, 2021, to February 26, 2021.  
 
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 pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found 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 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 HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0013M) provided on June 28, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Non-coverage was reaffirmed for procedure 
codes 0012M and 0013M for CxBladder. 
 
We looked at the file and Medicare rules. The testing performed was CxBladder testing. This service is non-
covered. Based on this information, we decided that Medicare rules for coverage of the lab testing have not 
been met. Therefore, we decided that the Plan does not have to pay for lab testing (0013M) provided on June 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up on tooth #12, 13, and 19 (D2940) provided 
on February 9, 2023. 
 
You asked the Plan to pay for the core build up. You say that you were advised the core build up would be 
covered. The Plan denied your request. The Plan says that there is no history of root canal therapy on tooth #12, 
13, and 19. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers core build up 
when the services are medically necessary and reasonable.  
 
 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 core build up. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that a review of the documentation indicates 
that the radiographs provided appear to be post-op of the placement of the crowns. Therefore, a determination 
of the amount of coronal breakdown could not be made and if core build up was needed for support and 
retention of the crowns. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core build up have not been met. Therefore, we decided that the Plan does 
not have to pay for the core build up on tooth #12, 13, and 19 (D2940) provided on February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 24, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Varithena ablation of the right GSV along with EVLT 
of the right SSV. 
 
You asked the Plan to pre-approve Varithena ablation of the right GSV along with EVLT of the right SSV. 
You say that the requested Varithena ablation of the right GSV along with EVLT of the right SSV is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
Varithena ablation of the right GSV along with EVLT of the right SSV. 
 
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 Varithena ablation of the right GSV 
along with EVLT of the right SSV. Our reviewer says that the enrollee does not meet criteria for the requested 
Varithena ablation of the right GSV along with EVLT of the right SSV. Our physician reviewer found 
coverage criteria require that there be an absence of significant peripheral artery disease.  In this case, the 
enrollee has significant peripheral artery disease requiring treatment.  The enrollee is relatively young, and the 
documentation does not support the reasonableness/medical necessity of destroying the enrollees saphenous 
vein(s) in the setting of severe peripheral artery disease as endovascular options often lack durability.  
Destruction of the enrollees saphenous vein could potentially deny the enrollees best option for limb salvage 
and, if a bypass was ever performed, this would in fact also resolve the associated reflux.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Varithena ablation of the right GSV along with EVLT of the right SSV have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Varithena ablation of the right 
GSV along with EVLT of the right SSV.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on May 10, 2022. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the provider 
has not submitted any clinical records to support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the anesthesia services have been met.  
Therefore, we decided that the Plan does not have to pay for anesthesia services provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
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 MyoPro Orthosis is not known to 
be effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes. The MyoPro is not the standard of care for this enrollee's condition or in widespread use for this 
enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the 
MyoPro Orthosis will improve the long term outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for dates of service November 
5, 2022, to November 11, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that you believe this claim should be processed 
as in-network. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for dates of service November 5, 2022, to November 11, 2022.
Appeal type: Surgery
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 a CardioMEMS device 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).