Persius/hicric huggingface dataset:
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 enrollee needs this device due to 
worsening heart failure The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMs device has not been demonstrated in the peer-reviewed literature. 
 
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 that 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 enrollee's 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy procedure provided on April 
12, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy procedure. You say that this service should be 
fully covered. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for a colonoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a colonoscopy procedure provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that a therapeutic CGM and 
supplies are medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM and supplies. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found that the enrollee is not 
using insulin and is not having low blood sugars that are documented in the chart. The enrollee is not on 
medications that would typically cause low blood sugars. Although a CGM might indeed help the enrollee 
control diet and blood sugars better, criteria for coverage are not met. If insulin is added to lower the a1c from 
11.6, then the case should be re-reviewed as the enrollee would then meet criteria for CGM coverage. 
 
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 therapeutic CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic CGM and supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging provided 
on February 28, 2023. 
 
You asked the Plan to waive the copayment for a myocardial perfusion imaging. You say that you disagree 
with the copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for a myocardial perfusion imaging. This item/service falls 
within the in-network outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a myocardial perfusion imaging provided on February 28, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary ventilation and perfusion imaging. 
 
You asked the Plan to pre-approve pulmonary ventilation and perfusion imaging. You say that pulmonary 
ventilation and perfusion imaging is medically necessary. The Plan denied your request. The Plan says 
pulmonary ventilation and perfusion imaging 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 pulmonary ventilation and perfusion 
imaging. Our reviewer says that the requested pulmonary ventilation and perfusion imaging is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that a review of the records 
showed the enrollee status post mitral prolapse repair and Raynaud's disease. No chest x-ray result and no 
discussion concerning the need or indication for VQ scan. Such scans are commonly done when there is contraindication to a computed tomography angiography (CTA) looking for emboli but no such discussion is in 
the records nor is there an order for VQ scan. Medical necessity of the requested VQ scan has not been 
established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary ventilation and perfusion imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pulmonary ventilation and perfusion imaging.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on February 16, 2023. 
 
You asked the Plan to pay for the x-ray services. You say that there was not time to get authorization. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-ray services 
provided on February 16, 2023.
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 need need physical therapy services and have no 
one in the home that can help with the needed care. The Plan denied your request. The Plan says ongoing 
skilled care can be provided in an alternative setting. 
 
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 that you do not require treatment by multiple therapies. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a secondary membranous cataract 
procedure provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for a secondary membranous cataract procedure. You say that you 
are on a fixed income. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $170 
copayment for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an ambulatory surgical center. 
 
You have been asked to pay a $170 copayment for a secondary membranous cataract procedure. This item/service falls within the other outpatient procedures and services, including, but not limited to, diagnostic 
and therapeutic endoscopy, and outpatient surgery performed in an ambulatory surgical center benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a secondary membranous cataract procedure provided on 
April 11, 2023.
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 acute care will provide a structured environment that 
will significantly enhance the enrollee's recovery. The Plan denied your request. The Plan says the records do 
not show that the enrollee requires intensive services consisting of 3 hours of daily therapy for their 
rehabilitation. 
 
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 do not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network debridement procedure 
provided on April 07, 2023. 
 
You asked the Plan to waive the copayment for an in-network debridement procedure. You say that you 
werent in a procedure room, and the provider hardly did anything. Please reconsider. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital.  
You have been asked to pay a $270 copayment for an in-network debridement procedure. This item/service 
falls within the for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network debridement procedure provided on April 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial and say the requested 
IRF services are necessary for you to heal. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services requested do not mee 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on April 5, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
are appealing the denied case. The Plan denied your request. The Plan says Tetanus, Diphtheria Toxoids and 
Acellular Pertussis vaccine is not eligible under the Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on April 5, 2023.  
 
Benefits for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the dermatology office visit provided on 
April 27, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the office visit. You say that you are requesting 
reconsideration of the denied reimbursement. The Plan denied your request. The Plan says this service was not 
authorized. 
 
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 provide reimbursement 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 provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the 
dermatology office visit provided on April 27, 2023, by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab testing (0037U) provided on April 6, 2023. 
 
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 that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing is covered when the 
patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 lab testing. Our reviewer says that the 
service was medically necessary. Our physician reviewer found based on National Comprehensive Cancer 
Network Guidelines Version 2.2023 Gallbladder Cancer, patients with pT1b or greater tumors should undergo 
molecular profiling. This patient is at least a pT2a and would meet criteria. 
 
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 lab testing have been met. Therefore, we decided that the Plan has to pay for 
lab testing (0037U) provided on April 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says these services are not covered when provided OON. 
 
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 the laboratory services provided on December 7, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99283) rendered 
on August 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99283-25 remains 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 99283 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation from this date 
includes an expanded problem focused history and examination. However, the records do not support medical 
decision making of moderate complexity or show problems that were of moderate severity. The enrollee 
experienced an elbow fracture after falling without loss of consciousness or other injury and was stable.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99283) rendered on August 1, 2022.