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

 
We decided that the Plan does not have to pre-approve the CardioMEMs Implantable Hemodynamic Monitor 
device. 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the enrollee has class-three heart 
failure symptoms with heart failure hospitalizations within the past year, chronically elevated brain natriuretic 
peptides (BNPs), and chronic kidney disease. You say the implant is the best way to manage the enrollee's 
heart failure with the goal of reducing heart failure hospitalizations. The Plan denied your request. The Plan 
says the device is still considered investigational and experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMs device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that although the device has been approved by the Food and Drug Administration, more studies 
are needed in order to examine the long-term clinical outcomes establishing the value of CardioMEMS in 
patient 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 the CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs Implantable Hemodynamic Monitor device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on October 22,  2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the submitted medical records support the ambulance transport was medically necessary. 
The Plan denied your request. The Plan says our policy covers non-emergency ambulance transportation when 
it is the only way to safely and adequately transport a member or if other means of transporting a member are 
unsafe due to a medical condition. This claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport and ground mileage.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital to the enrollee's residence upon discharge was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport.  Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on October 22,  2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan. 
 
You asked the Plan to pre-approve Rocklatan. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan.   
Benefits for Rocklatan 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 pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) 
joint (64626). 
 
You asked the Plan to pre-approve an RFA for SI joint. You say that the enrollee is in pain. You say that this 
affecting their daily living. You say that the enrollee does not take any medication for the pain and can be at 
risk for falling due to the pain. The Plan denied your request. The Plan says the requested procedure is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint (SIJ) denervation is not 
considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an RFA for SI joint have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) for the sacroiliac (SI) joint (64626).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to your 
appointment. The Plan denied your request. The Plan says the requested trip exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. We verified that the requested trip is 
greater than 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial for LTACH. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care and is currently 
unstable for transfer. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and are able to 
be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing rendered on July 9, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says screening for Barrett's esophagus is not a covered screening service. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that there is no history of Barrett's esophagus. There is no specific clinical rationale for the requested 
laboratory test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the WATS cytopathology and histopathology diagnostic testing rendered on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on October 10, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you are requesting reconsideration for the services 
provided. 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 rest home visit provided 
on October 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on August 10, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration for the 
services provided. 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 outpatient mental health 
provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bimatoprost injection provided on 
December 05, 2022. 
 
You asked the Plan to waive the coinsurance for the bimatoprost injection. You say that you were told you 
would only have the office visit 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the bimatoprost injection. This item/service falls within the 
in-network Medicare Part B drugs 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. The total you owe for the injection is $412.67 ($2,063.33 allowed amount x 
20% coinsurance = $412.67). Therefore, we decided that the Plan does not have to waive the coinsurance for 
the bimatoprost injection provided on December 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal cap for bridge for teeth # 9 and 
#11 (D6751), and false tooth for bridge for tooth #10 (D6241). 
 
You asked the Plan to pre-approve a fixed bridge. You say that this is medically necessary. The Plan denied 
your request. The Plan says the x-rays your dentist sent us and said you are missing other teeth. Additionally, 
there appears to be several other non-restorable teeth including some of the existing bridge; that with the fact of 
there being several missing teeth bilaterally and the poor periodontal condition lends itself to be treated with a 
removable partial denture. 
 
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. The Plan covers a fixed bridge 
when the services are medically necessary and reasonable.  
 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 fixed bridge. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found The coverage for fixed bridges is limited 
to the replacement of a single maxillary anterior tooth if there are no other teeth missing in the arch. In this case 
there are multiple missing maxillary teeth bilaterally. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a fixed bridge have not been met. Therefore, we decided that the Plan does not 
have to pre-approve white glass with metal cap for bridge for teeth # 9 and #11 (D6751), and false tooth for 
bridge for tooth #10 (D6241).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Qutenza. 
 
You asked the Plan to pre-approve Qutenza. You say that Qutenza is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Qutenza has been prescribed for an off-label, not medically accepted 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Qutenza. Our reviewer says that 
Qutenza is not medically reasonable and necessary in this case. Our physician reviewer found that Qutenza is 
FDA-approved for the treatment of post-herpetic and diabetic peripheral neuropathy but has no indication for 
polyneuropathy, unspecified. This use is not supported by one of the major drug compendia or by clinical 
research that appears in a Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Qutenza.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222-57 billed for date of service December 
2, 2022. 
 
You asked the Plan to pay for procedure code 99222-57. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99222-57 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99222-57 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99222-57 is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99222-57 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99222-57 billed for date of service December 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 1, 2022, billed with 
code 75572. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that manifestation diagnosis codes are never 
permitted to be used as first listed or principal diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with principal diagnosis 
code I25.82 which is a manifestation code and cannot be paid. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on November 1, 2022, billed with code 75572.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records show that the ordered settings for the noninvasive ventilator can be 
delivered by a bi-level positive airway pressure (BiPAP) machine with average volume-assured pressure 
support average volume-assured pressure support (AVAPS) capability. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that there are 
no pulmonary function tests to confirm airways obstruction or assess severity. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. There was no arterial blood gas (ABG) done while stable to 
conform chronic C02 retention. If that is present, the patient may benefit from bilevel positive airway pressure 
(BiPAP) with AVAPS during sleep.  Medicare does not cover a home ventilator when used at settings that can 
be provided 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes A41.9 
and J96.01 rendered from September 11, 2022, to September 15, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated, after a post-service, 
post-payment clinical validation audit was performed to help ensure that the diagnosis codes on the claim 
supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.9 and J96.01. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that there were no signs or symptoms suggestive of organ failure directly as a result 
of dysregulated response to systemic infection that was life threatening. Sepsis 3 criteria was not met based on 
the provided documentation. Therefore, the code, A41.9, is not sufficiently supported for this admission. Also, 
there was no documentation of the patient with respiratory distress requiring high flow oxygen, bilevel positive 
airway pressure (BiPAP), or vent support to support the diagnosis of J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis codes A41.9 and J96.01 rendered from September 11, 2022, 
to September 15, 2022.