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

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that a CardioMEMS device is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a CardioMEMS device is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that CardioMEMS implantable devices are currently considered investigational and 
are not recommended by any professional societies/associations guidelines for management of heart failure. 
 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 implantation of a CardioMEMS device (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the cardiovascular stress test services, and 
the myocardial perfusion imaging provided by an in-network provider on March 22, 2022, and the total hip 
arthroplasty procedure, the x-rays of the hip, and the anesthesia services provided by an in-network provider on 
May 5, 2022. 
 You asked the Plan to waive the cost sharing for the stress test services, the myocardial perfusion imaging, the 
arthroplasty procedure, the x-rays, and the anesthesia services. You say that you do not understand the cost 
sharing. 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 20% 
coinsurance for in-network outpatient hospital diagnostic testing services, diagnostic radiological services, and 
x-ray services, and a 20% coinsurance for each in-network outpatient hospital facility visit, including physician 
or surgical charges. 
 
You have been asked to pay a $25.21 coinsurance for the stress test services, the myocardial perfusion imaging, 
and the x-rays ($126.05 allowed amount x .20 = $25.21). These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a 
$3163.77 coinsurance for the arthroplasty procedure and the anesthesia services ($15,818.86 allowed amount x 
.20 = $3163.77). These items/services fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 
cost sharing for the cardiovascular stress test services, and the myocardial perfusion imaging provided by an in-
network provider on March 22, 2022, and the total hip arthroplasty procedure, the x-rays of the hip, and the 
anesthesia services provided by an in-network provider on May 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for arthrocentesis, aspiration and/or injection, major joint or bursa provided 
on December 13, 2022. 
 
You asked the Plan to pay for arthrocentesis, aspiration and/or injection, major joint or bursa. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that charges for or in 
connection with services or supplies that are, as determined by us, considered to be experimental or 
investigational are excluded from coverage under the member's Plan. 
 
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 has not provided a Medicare rule or a coding rule or 
review to substantiate their denial. Therefore, we decided that the Plan has to pay for arthrocentesis, aspiration 
and/or injection, major joint or bursa provided on December 13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for admission to an IRF. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that you require ongoing physical and occupational therapy but does not show that you 
would require or tolerate an intensive rehabilitation regimen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission stating you need physical therapy because you are falling frequently. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that you require ongoing physical, occupational and speech therapy but does not show 
that you require an intensive rehabilitation regimen in an IRF setting. 
 
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: Favorable

 
We decided that the Plan has to pre-approve hyaluronan or derivative, triluron, for intra-articular injection, 1 
mg (J7332). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that this medication is given by injection directly into the knee joint. There are 
similar medications that are preferred by the health plan. They work in the same way as Triluron. As required 
by the medical policy, these medications must be tried first. The information provided shows that the enrollee 
has not already been treated with all these medications. 
 
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. A request for information was sent to the Plan requesting medical records. The 
records were not received. Therefore, we decided that the Plan has to pre-approve hyaluronan or derivative, 
triluron, for intra-articular injection, 1 mg (J7332).  
 
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 lumbar radiofrequency ablation (RFA) (64635, 
64636). 
 
You asked the Plan to pre-approve RFA. You say that the enrollee had two successful facet blocks with 95 to 
100% relief. The Plan denied your request. The Plan says the enrollee has not trialed conservative therapies. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain that has been present for a minimum 
of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated). 
 
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 RFA. Our reviewer says that the 
requested RFA are not medically necessary. Our physician reviewer found there is no documentation of 
conservative therapy or an explanation of why you cannot tolerate that therapy. Therefore, the reviewer found 
that the requested RFA are not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lumbar radiofrequency ablation (RFA) (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no documentation of chronic carbon dioxide (CO2) retention with an arterial blood gas 
(ABG) done while stable. If that is present, the enrollee may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
December 19, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility is not a hospital and has no affiliation with a 
hospital.  
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Therefore, we decided that the Plan does not have to pay for an emergency department 
visit provided on December 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that this procedure is less invasive and 
less expensive than the other surgeries available for your back issue. The Plan denied your request. The Plan 
says unproven and not medically necessary procedures are not covered by Medicare due to insufficient 
evidence of efficacy. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vertiflex Superion device (22869).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code(s) 95939, 95938, 95861, 95927, 95868, and 
95940 billed for date of service July 10, 2022. 
 
You asked the Plan to pay for procedure code(s) 95939, 95938, 95861, 95927, 95868, and 95940. You say that 
the claim was billed correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939, 95938, 95861, 
95927, 95868, and 95940. This means there is both a professional and technical component for the CPT 
code(s). In this case, an appropriate modifier to indicate the professional component has not been billed with 
CPT code(s) 95939, 95938, 95861, 95927, 95868, and 95940. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95939, 95938, 95861, 95927, 95868, and 95940 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95939, 95938, 95861, 
95927, 95868, and 95940 billed for date of service July 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement orthotic oral appliance, a tomography x-
ray (76100), a panoramic x-ray (70350) and a cephalogram (70355). 
 
You asked the Plan to pre-approve a replacement orthotic oral appliance and services. You say that the enrollee 
lost her occlusal orthotic appliance at a Superbowl party and requested a second one. The Plan denied your 
request. The Plan says the reasonable use lifetime for DME is five years unless there is irreparable damage 
from an accident or disaster. The item is not covered for replacement. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 
 
 The file shows that the enrollee was approved for an occlusal orthotic appliance on February 7, 2023. This 
appliance serves the same purpose as a replacement orthotic oral appliance. Medicare rules state that the 
reasonable useful lifetime of equipment is five years. The records do not show that you have irreparable 
damage due to an accident or disaster. Therefore, we decided that the Plan does not have to pre-approve a 
replacement orthotic oral appliance, a tomography x-ray (76100), a panoramic x-ray (70350) and a 
cephalogram (70355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery services (41899, G0330) with anesthesia 
(00170). 
 
You asked the Plan to pre-approve dental surgery services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental surgery services (41899, G0330) with anesthesia (00170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 26, 2021, to 
May 27, 2021. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says documentation does not support the 
billed 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 inpatient hospital services provided 
have been met. Specifically, medical records have not been provided for review. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on May 26, 2021, to May 27, 2021.
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 you are requesting an expedited 
reconsideration stating the enrollee currently meets LTACH admission criteria. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate in-patient care and is currently unstable for 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 appears to be unstable requiring additional treatment and should 
only require short-term additional acute care services that can safely be provided at the current facility until 
more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH 
would not be clinically advantageous and completion of treatment at the current facility is recommended. 
 
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.