Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
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 requested device is an approved 
study, and it is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
CardioMEMS device has been determined to be of uncertain value in the most recent guidelines and carries a 
risk of significant complications including death and severe pulmonary artery injury. The CardioMEMS device 
at this point should only be approved for enrollees enrolled in a clinical trial. There is no indication that this 
enrollee is enrolled in a clinical trial of the device. 
 
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 provided medical records and review of the current peer-reviewed medical literature 
do not document that use of the CardioMEMS device has been shown in controlled studies in a CMS-approved 
journal to result in long term health benefits in enrollees with heart failure. The American College of 
Cardiology states: "In patients with New York Heart Association (NYHA) class III heart failure (HF) with a 
HF hospitalization within the previous year, wireless monitoring of the pulmonary atresia (PA) pressure by an 
implanted hemodynamic monitor provides uncertain value." 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve eye surgery with an out-of-network provider. You say that you want the 
Plan to approve the services. The Plan denied your request. The Plan says the requested service is available 
with an in-network provider. 
 
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 
eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on May 11, 2023. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site. You say that you had 
a tooth extraction, which resulted in exposed bone. You also say that the grafting was put in place to prevent 
infection or further problems. The Plan denied your request. The Plan says procedure code  D7953, is not listed 
on the dental benefit grid as a covered service. 
 
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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft for ridge 
preservation - per site is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for a bone replacement graft for ridge preservation - per site (D7953) provided on May 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
approval of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee does have severe COPD with 
chronic respiratory failure as a consequence. The enrollee does meet requirement for treatment of their severe 
COPD, sleep apnea, and chronic respiratory failure with average volume-assured pressure support-automated 
expiratory (AVAPS AE) trilogy ventilator. The enrollee has been on this therapy since January 2020, and to 
discontinue will be substandard of care. Best practice would strongly recommend continuing the Trilogy 
ventilator. 
 
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 home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized 
and is ready for discharge from the acute care hospital. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval. 
 
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 there are no services that the enrollee requires that are not currently available. 
Continued care in the short-term acute hospital is appropriate until acute care is no longer required, at which 
time the enrollee can be transferred to a lower 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient diagnostic tests, an outpatient 
surgery and a specialist office visit provided on April 7, 2023, to April 8, 2023. 
 
You asked the Plan to waive the cost share for an outpatient diagnostic tests, an outpatient surgery and a 
specialist office visit. You say that you disagree with the cost share. 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 $750 deductible, a $20 copayment to outpatient diagnostic tests, a 
$125 copayment for outpatient surgery and a $35 copayment which applies to physician/practitioner 
services/specialist office visit.  
 The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests, 
outpatient surgery, physician/practitioner services/specialist office visit benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible, a $20 copayment for to 
outpatient diagnostic tests, a $125 copayment for outpatient surgery and a $35 copayment which applies, 
physician/practitioner services/specialist office visit. You are being asked to pay $674.90 towards your $750 
deductible. The total amount you are being asked to pay is $854.90 ($674.90 + $20 + $125 + $35 = $854.90). 
This cost sharing is a contractual obligation that had not been met at the time an outpatient diagnostic tests, an 
outpatient surgery and a specialist office visit  was received on April 7, 2023 to April 8, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for an outpatient diagnostic tests, an outpatient 
surgery and a specialist office visit provided on April 7, 2023, to April 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service December 
30, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0482 billed for date of service December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 18, 2022, to 
November 16, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted to the 
Plan. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 18, 2022. The NOA was not received by the Plan until March 16, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 18, 2022, to November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed (E0265) provided on October 
16, 2022. 
 
You asked the Plan to pay for the total electric hospital bed. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed (E0265) provided on October 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - mandibular (D5140) provided on 
October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the service should be paid. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. This benefit includes the 
requested item or service, but you pay 100% of charges beyond your $2,000 allowance or if you exceed a 
service limit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $125 on date of service July 12, 2022, and paid $1,875 on date of service July 28, 2022 
($125 + $1,875 = $2,000). After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, this benefit has been exhausted as of October 18, 2022. Therefore, we decided that 
the Plan does not have to pay for immediate denture - mandibular (D5140) provided on October 18, 2022.
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 January 26, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. 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 January 
26, 2023.
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 the enrollee has multi-disciplinary acute 
care needs that require daily specialized physician management for multiple medically complex issues. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for an LTACH 
admission. 
 
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 there are no services that the enrollee requires that are not currently available. 
Continued care in the short-term acute hospital is appropriate until acute care is no longer required, at which 
time the enrollee can be transferred to a lower 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 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: 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 you were admitted for surgical repair of a hip fracture after a fall. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 magnetic resonance imaging shows spinal stenosis. The cause of back pain is not 
clear. 
 
   
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 the Intracept procedure (64628).
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 the enrollee's complex needs cannot be 
met at a lower level of care. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval. 
 
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 there are no services that the enrollee requires that are not currently available. 
Continued care in the short-term acute hospital is appropriate until acute care is no longer required, at which 
time the enrollee can be transferred to a lower 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 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 facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet joint 
injections 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 the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has a history of 
chronic low back pain, primarily axial in nature and worse with extension. The enrollee is also status/post L5-
S1 anterior lumbar interbody fusion.  
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast lift. 
 You asked the Plan to pre-approve a breast lift. You say that the requested breast lift is medically necessary. 
The Plan denied your request. The Plan says this surgery is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast lift. Our reviewer says that this 
procedure is not medically necessary. Our reviewer found documents provided indicate that the requested 
service is to improve appearance and would therefore be cosmetic in nature. 
 
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 breast lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a breast lift.