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

 
We decided that the Plan does not have to pay for hydration therapy provided on February 1, 2023. 
 
You asked the Plan to pay for hydration therapy. You say that this was an emergency service and meaningfully 
needed by the patient. The Plan denied your request. The Plan says the member was seen in a free-standing 
emergency room on February 1, 2023, for a headache and received a Reglan infusion as part of his treatment. 
Hydration services used for intravenous (IV) drug injections are considered are considered not medically 
reasonable and necessary. 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. Based on this information, we decided that Medicare rules for coverage of hydration 
therapy have not been met. Therefore, we decided that the Plan does not have to pay for hydration therapy 
provided on February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as U0004, 99001 and U0005 
provided March 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the claim was submitted after the 
timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 5, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory service coded as U0004, 99001 and U0005 
provided March 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95908 and 95938 billed for date of 
service October 12, 2022. 
 
You asked the Plan to pay for procedure codes 95886, 95908 and 95938. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic services furnished to hospital 
outpatients are paid under the OPPS to the hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 95886, 95908 and 95938 have not been met. Specifically, the records suggest that 
these services were rendered in an outpatient facility. The procedure codes at issue have a 
professional/technical component indicator of 1. This means that these codes have a professional and technical 
component. These codes have not been billed with the appropriate modifier to indicate that they are for the professional component. Payment for the technical component of these codes is included in the payment to the 
facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have 
to pay for procedure codes 95886, 95908 and 95938 billed for date of service October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee arthroscopy. 
 
You asked the Plan to pre-approve left knee arthroscopy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 left knee arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of an adequate trial and failure of physical therapy for knee 
pain. More conservative measures are 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 left knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left knee arthroscopy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
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 a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was successfully treated with BiPAP and is ordered BiPAP as an out-patient. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The physician requests authorization for cardiac 
catheterization with percutaneous angioplasty (PCI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had no cardiac symptoms 
or signs in a recent cardiology visit. As such, it is not clear that a guideline-supported indication for cardiac 
catheterization with percutaneous angioplasty is present. The requested procedure is therefore not reasonable or 
medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve The physician requests authorization for cardiac catheterization with percutaneous 
angioplasty (PCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral corpectomy (63081). 
 
You asked the Plan to pre-approve vertebral corpectomy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 vertebral corpectomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no radiographic documentation of compression behind the vertebral body on 
any imaging report. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebral corpectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vertebral corpectomy (63081).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission to regain the 
maximum level of function. The Plan denied your request. The Plan says that the enrollee's condition does not 
meet the Medicare rules for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found based on the documentation submitted, the enrollee's condition is considered to be complex and fragile. 
There is every reason to expect that the enrollee will participate in and benefit from services provided at 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for echocardiography services (93306) and initial hospital care (99223) 
provided out-of-area (OOA) on March 26, 2023, and April 4, 2023, at the in-network benefit level.  
 
You asked the Plan to pay for the OOA echocardiography services and initial hospital care, at the in-network 
benefit level. You say that you were assured that OOA services would be covered as if they were in-network. 
You say that the services in dispute were initiated from an emergency visit.  The Plan denied your request. The 
Plan says that the OON cost-sharing was appropriately applied.  
 
The Plan must follow Medicare rules. Medicare says that plans must pay for emergency and urgently needed 
services. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and 
forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. Without this information, we are unable to make a 
determination as to whether the OOA services that are in dispute were urgent or emergent in nature. Therefore, 
we decided that the Plan has to pay for echocardiography services (93306) and initial hospital care (99223) 
provided out-of-area (OOA) on March 26, 2023, and April 4, 2023, at the in-network benefit level.   
 
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 the enrollee would benefit from short term IRF 
rehabilitation to improve functional mobility, activities of daily living and gait, and to decrease acute care 
hospital readmission and caregiver burden. 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that TTFT is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you had a brain tumor 
(glioblastoma) that was removed by total resection on January 4, 2023. You tolerated surgery well and finished 
radiation therapy in March of 2023. The records do not support that the TTFT will be used for an average of 18 
hours per day; therefore, the criteria for coverage are not met and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tumor treatment field therapy (TTFT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing services (G0299). 
 You asked the Plan to pre-approve the home health services. You say that the medical records support the need 
for the skilled nursing visits. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. Therefore, the requested home health skilled nursing services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health skilled nursing services (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spineology Optimesh cage. 
 
You asked the Plan to pre-approve Spineology Optimesh. You say that the enrollee could not complete 
physical therapy. The Plan denied your request. The Plan says the clinical value and effectiveness of this 
procedure have not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Spineology Optimesh. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Spineology Optimesh cage is experimental when used in spine surgery. 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 Spineology Optimesh have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Spineology Optimesh cage.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) and infectious agent 
antigen detection by immunoassay technique (87428) provided on March 9, 2023. 
 
You asked the Plan to pay for the emergency department visit and infectious agent antigen detection by 
immunoassay technique. You say that you would like this claim to be reprocessed. The Plan denied your 
request. The Plan says the certification was requested from the appealing provider, but the information was not 
received.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Medicare rules also 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. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283) 
and infectious agent antigen detection by immunoassay technique (87428) provided on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service January 11, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was ordered based on medical 
necessity. The Plan denied your request. The Plan says a panel cannot be unbundled and billed as individual 
components. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the panel testing billed for date of service January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) (0398T). 
 
You asked the Plan to pre-approve a MRgFUS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS unilateral thalamotomy is considered 
medically reasonable and necessary in patients who meet specific criteria. 
 
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 MRgFUS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records in this case do not 
document the enrollee has moderate to severe postural or intention tremor of the dominant hand (defined by a 
score of =2 on the Clinical Rating Scale for Tremor (CRST)) or a disabling tremor (defined by a score of =2 on 
any of the eight items in the disability subsection of the CRST) and is not a surgical candidate for deep-brain 
stimulation (e.g., advanced age, anticoagulant therapy, or surgical comorbidities) as required by the LCD.  
 
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 MRgFUS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).