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

 
We decided that the Plan does not have to pre-approve the coronary calcification score. 
 
You asked the Plan to pre-approve the coronary calcification score. You say that the calcium score test is 
medically necessary due to your history of a heart attack and risk factors. The Plan denied your request. The 
Plan says the coronary calcium score is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the coronary calcification score. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have a medical 
history of hypertension and dyslipidemia. You have no cardiac symptoms, and already on medication. A 
coronary calcification score is currently indicated in individuals with a moderate, ten-year risk of 
atherosclerotic cardiovascular disease (ASCVD) when the person does not wish to take Statins. The record 
shows you are already on Statins and tolerating them well. This means there will not be a benefit from the test. 
 
  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 coronary calcification score have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the coronary calcification score.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cardiology services (93229, 99214, 93228) provided on 
April 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Cardiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 had network providers 
available who could have provided the ervices at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for Cardiology services (93229, 99214, 93228) provided on April 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a lower level of care cannot 
accommodate intravenous infusions every four hours, and the enrollee is unable to go home or to outpatient 
clinic. You also say that an LTACH is the best option for full recovery. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. Our reviewer 
also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Implantable Loop Recorder 
 
You asked the Plan to pre-approve an Implantable Loop Recorder. You say that an Implantable Loop Recorder 
is medically necessary. The Plan denied your request. The Plan says an Implantable Loop Recorder 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 Implantable Loop Recorder. Our 
reviewer says that the requested Implantable Loop Recorder is not considered medically reasonable and 
necessary in this case. Our physician reviewer found an implantable cardiac loop recorder is indicated for 
evaluation of recurrent syncope (three or more), or cryptogenic cerebrovascular accident and stroke/transient 
ischaemic attack (CVA/TIA); all are missing in this case. 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 Implantable Loop Recorder have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Implantable Loop Recorder
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services (99233) provided on August 4, 2022. 
 
You asked the Plan to pay for physician services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the claim was a duplicate. 
 
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 any documentation showing that this claim was a 
duplicate. Therefore, we decided that the Plan has to pay for physician services (99233) provided on August 4, 
2022.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grocery and meals program. 
 
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 you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. The Plan 
contract has a supplemental benefit that allows for grocery boxes for enrollees with diabetes and depression or 
depressive disorders. 
 
We looked at the file and the Plans rules. The file shows that you are not diagnosed with both diabetes and depression/depressive disorders. Based on this information, we decided that Plans rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a grocery and 
meals program.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System 
for implantation of Superion interspinous spacers (ISS) (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion Indirect Decompression System for implantation of 
Superion interspinous spacers. You say that the service is medically necessary. The Plan denied your request. 
The Plan says this service is considered experimental. 
 
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 Vertiflex Superion Indirect 
Decompression System for implantation of Superion interspinous spacers. Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found current 
evidence-based medical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term 
peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. 
 
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 Vertiflex Superion Indirect Decompression System for implantation of 
Superion interspinous spacers have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion Indirect Decompression System for implantation of Superion interspinous 
spacers (ISS) (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve the medication. You say that you have asthma and have been hospitalized 
many times due to it. You also say that your doctor recommended this. 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 Tezspire.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the Matrion skin substitute. 
 
You asked the Plan to pre-approve the Matrion skin substitute. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the requested skin substitute has not yet been shown to safe, 
efficacious, or superior to standard treatments. 
 
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 the Matrion skin substitute. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enclosed medical documentation supports that this patient has undergone standard 
of care treatments for their chronic diabetic foot ulcerations. They have been offloaded, the ulcerations have 
been debrided routinely, they have received antibiotics, x-rays demonstrate no bone involvement, and they 
have received good standard of care wound dressings. Unfortunately, the wounds continue.  Medical evidence 
suggests that skin substitutes such as Matrion create a matrix, lattice, and amniotic cells that allows for 
regeneration of skin. They are also noted to reduce bio burden in a wound and improve healing. Although most 
studies advise that further research is necessary, it is my opinion that in this particular case the Matrion skin 
substitute would be at least as beneficial as continued wound debridement and dressings, and possibly even 
create an expediated healing of the ulcerations. 
 
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 Matrion skin substitute have been met. Therefore, we decided that the Plan 
has to pre-approve the Matrion skin substitute.  
 
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. The Plan denied your request. The Plan says the enrollee's records 
do not require an intensive and coordinated interdisciplinary approach to your rehab and your rehab is not 
complex, services needed can be provided safely in other settings, at a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 20, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 20, 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. The Plan denied your request. The Plan says the information we 
have about the enrollee's condition does not meet all the requirements; services may be provided safely in 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ileostomy supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve ileostomy supplies from an out-of-network provider. You say that the 
enrollee thought this provider was in-network and this brand works the best for the enrollee. The Plan denied 
your request. The Plan says the provider is out-of-network. These services/items are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ileostomy supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on September 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that it was medically necessary for the enrollee to 
receive treatment. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and authorization was not obtained. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physician visit provided on September 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual tilt-in-space wheelchair with recline and custom 
seating system. 
 
You asked the Plan to pre-approve manual wheelchair components. You say that you are appealing this denial 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rule state that tilt-in-space manual wheelchairs and wheelchair 
seating components may be covered if 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 manual wheelchair components. Our 
reviewer says that the enrollee does not meet the criteria for these components. Our physician reviewer found 
the documentation does not indicate that the specialist has recommended a tilt-in-space manual wheelchair. 
Additionally, there is no indication that the enrollee has previously been recommended to have custom seating 
cushions. These components are 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 manual wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve manual tilt-in-space wheelchair with recline and custom seating system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraossous nerve ablation procedure (64628, 
64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says the enrollee does not 
meet the medically necessary criteria. this injection is considered 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show a diagnosis of lumbar radiculopathy with leg symptoms. The 
magnetic resonance imaging (MRI) shows facet joint degenerative joint disease, and the cause of back pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intracept intraossous nerve ablation procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on December 14, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on December 14, 2022.