Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a therapeutic continuous glucose monitor (Freestyle Libre). 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing with supporting 
documents. The Plan denied your request. The Plan says that the denial of authorization for this device is 
correct, because the enrollee has not provided a glucose monitoring log and there is no documentation of her 
sliding scale regimen or A1C. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and 
necessary for enrollees with diabetes who meet criteria referenced above. 
 
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 continuous glucose monitor. Our 
reviewer says that the enrollee meets the Medicare criteria for the requested continuous glucose monitor. Our 
physician reviewer found the enrollee takes insulin 4 times daily and is on frequently sliding scale. This 
continuous glucose monitor is medically reasonable and 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 continuous glucose monitor have been met. Therefore, we decided that the Plan 
has to pre-approve a therapeutic continuous glucose monitor (Freestyle Libre).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient treatment with an out-of-network tertiary 
level of care provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that there is a three-month waiting period for 
the enrollee to be seen by the Plan's in-network provider, and the enrollee had abnormal imaging that shows 
deterioration. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollee's needs. The enrollee's 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 outpatient treatment. Our reviewer says 
that the enrollee does not meet the criteria for the requested treatment with an out-of-network provider. Our 
physician reviewer found the enrollee is not currently having dystonia. She is being seen for pain issues. She is 
in a comprehensive management program at the Plan's in-network provider for patients with multiple problems 
that are both physical and involve mental health issues. Both the in-network and out-of-network providers have 
movement disorder programs, but a referral to the out-of-network provider would not involve any 
comprehensive management. It would be best for the enrollee to maintain her care with the Plan's in-network 
medical group for that reason. The in-network provider requires a neurology visit first since many movement 
disorders can be treated by general neurology. If necessary, the enrollee will be referred to the movement 
disorder clinic. The Plan's denial is medically justified on the basis that it is offering adequate care to meet the 
enrollee's medical needs through referral to their in-network provider. It is not necessary for the enrollee to be 
treated out-of-network to avoid a delay in care. There is nothing unique about the enrollee's condition that 
would make it medically necessary for her to see the requested out-of-network provider. The Plan has shown 
that they have an in-network provider that meets the standards of care required for treatment of 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 outpatient treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient treatment with an out-of-network tertiary level of care provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistance services provided on June 22, 2020. 
 
You asked the Plan to pay for the surgical assistance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the rendered services are not payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistance services 
provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0668). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when 
medically necessary. 
 
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 pneumatic compression device. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee has had at least four weeks of conservative therapy, including 
compression bandages, exercise, elevation of the limb, and trial of a non-segmented pneumatic compression 
device. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0668).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplemental benefits including transportation for non-
medical needs, financial assistance for healthy food purchases and/or electricity, water, and or/phone bill 
payments, and home assistance services (repairs). 
 
You asked the Plan to pre-approve these services. You say that the Plan denied your request. The Plan says you 
do not meet the criteria for coverage. 
 
Medicare does not cover non-medical transportation, allowance for healthy food or home service bills, or home 
assistance services. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that 
reason, the Plan's coverage rules apply in this case. The Plan covers supplemental benefits for enrollees with 
chronic illness who meet specific criteria. 
 
We looked at your request, the records in the case file, and the rules. The file shows that you do not have a 
chronic illness that meets the Plan's criteria for coverage of the requested services. Based on this information, 
we decided that the Plan's rules for coverage of the supplemental benefits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve supplemental benefits including transportation for non-
medical needs, financial assistance for healthy food purchases and/or electricity, water, and or/phone bill 
payments, and home assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper and lower partial denture. 
 
You asked the Plan to pre-approve these services. You say that you cannot use your current dentures. The Plan 
denied your request. The Plan says the request exceeds the benefit limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one partial 
denture with cast metal framework every five years.   
 
We looked at the file and the Plan's rules. The file shows that you previously received partial dentures on 
January 30, 2020 and February 21, 2020. You are not eligible for new dentures until five years have passed 
from these dates. Therefore, we decided that the Plan does not have to pre-approve an upper and lower partial denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop recorder. 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that you would like reconsideration 
because you have a weak heartbeat that skips beats. The Plan denied your request. The Plan says the medical 
records show that you have not had syncope. 
 
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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record does not include evidence of atrial fibrillation on external 
monitoring. There is also no documentation of syncope. Since there are no syncope coverage criteria for an 
implantable loop recorder is not met. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantable loop recorder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive dental exam and intraoral complete series 
of radiographic images received on September 8, 2020. 
 
You asked the Plan to pay for the comprehensive dental exam and intraoral complete series of radiographic 
images. You say that the previous provider wanted to perform a root canal but you did not agree with that 
option a preferred a bridge. The Plan denied your request. The Plan says the services received exceed your 
benefit limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. Review of the file shows that these services are covered once every 
three plan years. You previously received these services on July 1, 2020. Three years had not passed since your 
previous comprehensive dental exam and intraoral complete series of radiographic images. Therefore, we 
decided that the Plan does not have to pay for the comprehensive dental exam and intraoral complete series of 
radiographic images received on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires, per pair (A4557 x 2) provided on  
September 12, 2020. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items provided are not a covered benefit under 
the enrollee's contractual policy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Additionally, the replacement of lead wires more often than every twelve months 
would rarely be reasonable and necessary.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these items have not been met. Specifically, a TENS unit has been purchased in the previous 
twelve months on April 12, 2020, May 12, 2020, and June 12, 2020. Medicare rules state that replacement of 
lead wires more often than every twelve months would rarely be reasonable and necessary. Additional records 
have not been provided to support the medical necessity of the additional lead wires provided. Therefore, we 
decided that the Plan does not have to pay for the lead wires, per pair (A4557 x 2) provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve dialysis care. You say that the enrollee should remain at your facility for 
continuity of care. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 
provider. The Plan also says that they have approved 1 month of continuity with the out-of-network provider so 
the enrollee can transition to an in-network dialysis provider. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 has back pain and spinal 
stenosis. The requested Vertiflex Superion spacer is considered experimental in nature, as more research is 
needed to show safety and efficacy. There is no spinal instability. The services are not the standard of care and 
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 a Vertiflex Superion spacer.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the patient would benefit greatly from an inpatient 
rehabilitation program. The Plan denied your request. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a subdural 
hematoma and fractured humerus after a fall. The enrollee's medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9239 and D9243) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 Plan's 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 services (D9239 and D9243) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not supported by the documentation. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the 
drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
coded G0483 provided on
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81206, 81162, 81292, 81295, 81298, 81301, 
81317, 81321, 81401) provided June 1, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services must be reported with the correct CPT code. 
 
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 CPT codes 81206, 81162, 81292, 81295, 81298, 81301,81317, 81321, and 81401 are not 
supported in the medical record. Specifically, per Medicare Local Coverage Article: Billing and Coding: 
MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in Solid Tumor Cancers (A55624), 
this procedure cannot be reported unbundled and must be reported using CPT code 81479. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81206, 81162, 81292, 81295, 81298, 81301, 
81317, 81321, 81401) provided June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the eyeglass frames (V2025) and lenses 
(V2781) rendered by the out of network (OON) provider on August 17, 2020. 
 
You asked the Plan to issue reimbursement for the eyeglasses. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the eyeglasses 
are not covered as they were rendered by an out of network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage.  
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Specifically, the eyeglasses were purchased from an out of 
network provider.  
The contract states that the eyewear must be rendered by a provider within the Plan's network.  Therefore, we 
decided that the Plan does not have to issue reimbursement for the eyeglass frames (V2025) and lenses 
(V2781) rendered by the out of network (OON) provider on August 17, 2020.