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

 
We decided that the Plan does not have to pre-approve a percutaneous arteriovenous fistula creation, upper 
extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation 
procedures (Ellipsys EndoAVF System) (36836). 
 
You asked the Plan to pre-approve the Ellipsys EndoAVF System. You say that the enrollee would benefit 
from this less invasive procedure versus the traditional atrioventricular (AV) access creation which normally 
requires general anesthesia. The Plan denied your request. The Plan says there is not enough proof that shows 
this procedure is as safe and as effective as other standard treatment options. 
 
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 Ellipsys EndoAVF System. Our 
reviewer says that the requested Ellipsys EndoAVF System is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates the reason for 
choosing the procedure in question was to reduce the level of anesthesia. The reviewer found that the plan is 
for a nerve block with MAC, a very common method of anesthesia for standard fistula creation. The reviewer 
found that the documentation does not demonstrate that the procedure in question is necessary. Therefore, the 
reviewer found that the requested procedure is 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 the Ellipsys EndoAVF System have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous arteriovenous fistula creation, upper extremity, single 
access of both the peripheral artery and peripheral vein, including fistula maturation procedures (Ellipsys 
EndoAVF System) (36836).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the adverse determination and request an additional review with the information included which supports 
all payer requirements are met. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the new patient office visit provided by an 
out-of-network provider on December 29, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you do not agree with 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. Your 
contract with the Plan says that there is a $1500 out-of-network deductible which applies to the office visit.   
 
You have been asked to pay a $70.54 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1500 out-of-network deductible which applies to 
physician/practitioner services, including doctors office visits. This cost sharing is a contractual obligation that 
had not been met at the time the office visit was provided on December 29, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for the new patient office visit provided by an out-of-network 
provider on December 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 7, 2023. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 consultations with an out-of-network provider. 
 
You asked the Plan to pre-approve 6 consultations. You say that the enrollee was referred for a liver transplant. 
You also say that this is medically necessary. The Plan denied your request. The Plan says there is a liver 
specialist available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 6 consultations. Our reviewer says that 
the request for 6 out-of-network visits is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate why referral to the out-of-network provider is medically necessary. The 
reviewer found there is a liver specialist who meets the standard of care and can determine whether the enrollee 
requires liver care beyond what can be provided in-network. Therefore, the reviewer found that the requested 
out-of-network care is 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 6 consultations have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 consultations with an out-of-network provider.
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 is not able to do daily activities and is at 
high risk of being put back into the hospital, the Inpatient Rehabilitation Facility is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records show to not require a rehabilitation doctor at 
least 3 times a week. Services needed may be provided safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 a heel lift (A9999). 
 
You asked the Plan to pre-approve a heel lift. You say that a heel lift is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet are covered only when the shoe is an integral part of a 
brace. The Plan follows these same rules.   
 
The records show that you do not wear a leg brace. Although a heel lift may be appropriate for you, neither 
Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan 
does not have to pre-approve a heel lift (A9999).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring, from outside 
the operating room (remote or nearby) and nerve conduction studies provided on October 20, 2022. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring, from outside the 
operating room (remote or nearby) and nerve conduction studies. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). Related services performed in connection with the denied procedure are also not covered. As well as: 
Charges for or in connection with services or supplies that are, as determined by us, considering 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, a Plan rule, a coding rule 
or a medical review to substantiate their denial. Therefore, we decided that the Plan has to pay for continuous 
intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) and nerve 
conduction studies provided on October 20, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab.  
You asked the Plan to pre-approve Rituximab. You say that Rituximab is medically necessary. The Plan denied 
your request. The Plan says a trial of Ruxience and Riabni is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituximab. Our reviewer says that 
Rituximab is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituximab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out-of-network provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the enrollee is still tapering down their 
medication. You say that the enrollee contacted the network facilities and they do not have providers to handle 
their particular problems. You also say that it is necessary for the enrollee's health and safety to continue 
treatment with their provider. The Plan denied your request. The Plan says there are in-network providers that 
can provide the requested services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 outpatient services. Our reviewer 
says that the request for continued out-of-network care is not medically necessary. Our physician reviewer 
found the medical records provided do not indicate that the enrollee is currently receiving any active treatment 
and/or medical management of their condition that makes it medically necessary for this enrollee to continue 
care with the out-of-network psychiatrist, as requested. The reviewer found that there is no documentation that 
there is anything unique about this enrollees condition that would make it medically necessary for him to 
continue care with their current provider. The reviewer also found that the enrollee's care can be safely 
transitioned to a qualified Plan provider. Therefore, the reviewer found that the request for continued out-of-
network care is 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 the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve office visits with an out-of-network provider.
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 were independent before hospitalization and 
want to return to this. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 a power wheelchair and accessories (E0973x2, E0955, 
E2622, K0040x2, E1028, E2611, K0848, E2361, A9270x3) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says you must receive services and 
items from a network provider. These items are available by a provider in your network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and accessories (E0973x2, E0955, E2622, K0040x2, E1028, E2611, K0848, E2361, 
A9270x3) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 24, 2022, to May 
23, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 24, 2022. The NOA was not received by the Plan until May 25, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided 
April 24, 2022, to May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U for date of service March 10, 2023. 
 
You asked the Plan to pay for procedure code 0241U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U for date 
of service March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from the additional therapy in an 
IRF setting to address functional deficits. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77022 billed for October 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 77022 is 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 77022 is magnetic resonance imaging guidance for, and 
monitoring of, parenchymal tissue ablation. 
 
We find that CPT code 77022 is not supported in the medical record. Specifically, there are no medical records 
to support that the service was performed on the billed date of service. 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 pay for procedure code 77022 billed for October 26, 2022.