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

We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Codes: 33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the device is not 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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure.  Medicare coverage 
criteria are not met, since the device should still be considered experimental or investigational. 
 
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 device (CPT Codes: 33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve musculokeletal surgery (CPT Code 22899). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure remains experimental. More research is needed to show safety and 
efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve musculokeletal surgery (CPT Code 22899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup (A2970). 
 
You asked the Plan to pre-approve the battery backup. You say that the battery is medically necessary. The 
Plan denied your request. The Plan says Medicare does not allowed payment for power generators or 
alternative power sources. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup (A2970).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide sensors for use with an interstitial continuous glucose 
monitor. 
 
You asked the Plan to provide sensors (A9276). You say that you need sensors for a Dexcom G5 continuous 
glucose monitor. The Plan denied your request. The Plan says you are authorized for supplies for a Dexcom G5 
CGM but the code submitted is incorrect. 
 
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 A9276 is Sensor; invasive (e.g., subcutaneous), 
disposable, for use with interstitial continuous glucose monitoring system.. 
 
We find that CPT code A9276 is for a non-covered interstitial type CGM. Interstitial CGMs and their supplies 
are not covered by Medicare. Therefore, we decided that the Plan does not have to provide sensors for use with 
an interstitial continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection services provided on May 13, 
2020. 
 
You asked the Plan to waive the coinsurance for the injection services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received injection services on the date of service at issue in this appeal. The 
Plan says that the correct cost share has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on 
May 13, 2020. You have been asked to pay a 20% coinsurance for the injection services, totaling $783.85. The 
injection services fall within the Medicare Part B prescription 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the injection services provided on May 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health care services with the out-of-
network provider. 
 
You asked the Plan to pre-approve continued home health care services with the out-of-network provider. You 
say that the continued home health care services with the out-of-network provider is medically necessary. The 
Plan denied your request. The Plan says the enrollee can transition to an in-network home health care provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
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 continued home health care services 
with the out-of-network provider. Our reviewer says that the continued home health care services with the out-
of-network provider is not medically necessary. Our physician reviewer found in order to require Home health 
care skilled services, the member must be confined to the home, under the care of a physician, and receiving 
services under a plan of care established and periodically reviewed by a physician.  Additionally, the member 
must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language 
pathology; or have a continuing need for occupational therapy.  Being homebound means leaving home is a 
major effort.   
 
In this case, the documentation doesn't support that the member requires skilled nursing services or skilled 
rehab services from an out of network Home Health agency to provide treatment that is medically necessary. 
The services she is receiving are not unique to a specific Home Health Agency and could be performed by an 
in-network Home health agency.  She is slowly improving with therapy.  She is ambulating household 
distances with a walker and has been medically stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued home health care services with the out-of-network provider have not 
been met. Therefore, we decided that the Plan does not have to pre-approve continued home health care 
services with the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day Sensor kit continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day Sensor kit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
covered by Medicare when all of the following coverage criteria (1-6) are met: 
 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiary?s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person 
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. Review of the file does not support that you test your blood at least 
four times a day with changed to the amount of insulin based on your readings. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 14-day Sensor kit have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day Sensor kit continuous glucose 
monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery (CPT Code: 20930, 20931, 20936, 22551 
and 22845). 
 
You asked the Plan to pre-approve the services. You say that the member has cervical radiculopathy confirmed 
on a magnetic resonance imaging (MRI). You state the member has failed physical therapy and various 
treatments. You state that surgery is medically necessary to improve the member's well-being. The Plan denied 
your request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found criteria for surgery are not met. There is no correlation between exam and imaging. There is no 
spinal instability or severe deficit or stenosis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery (CPT Code: 20930, 20931, 20936, 22551 and 22845).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the Advanced Practice Registered Nurse (APRN) evaluation provided 
on April 29, 2020. 
 
You asked the Plan to pay for the APRN evaluation. You say that this denial is in error because this provider is 
an APRN and able to bill Medicare directly. The Plan denied your request. The Plan says that this coding edit 
invoked correctly because the taxonomy listed on the claim is not an APRN taxonomy. Therefore, this must be 
rebilled. 
 
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. In this case, the claim was denied stating that the provider is not eligible to 
directly bill for Medicare-covered services. However, the NPI billed on this claim clearly shows that the billing 
provider is a licensed APRN. Medicare allows APRNs to bill directly for their services. The Plan indicates that 
this is not payable because the taxonomy code reported on the claim is not the provider's primary taxonomy 
and that a new claim must be filed with the correct taxonomy. We do not find any regulation which indicates 
that using the incorrect taxonomy is grounds for claim denial. The NPI record clearly indicates that this 
provider's primary taxonomy is APRN, and the secondary taxonomy is also listed as associated with the State 
APRN license. We find no evidence to suggest that this denial of payment is correct. Therefore, we decided 
that the Plan has to pay for the Advanced Practice Registered Nurse (APRN) evaluation provided on April 29, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information does now that this is urgent or emergent. 
 
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 referral to an out-of-network radiation oncologist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest spine 
(72146). 
 
You asked the Plan to pre-approve an MRI of the chest spine. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the chest spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found review of the records 
showed no discussion concerning the need for the MRI of the thoracic spine and in fact there was not an order 
for this exam found within the records. No repeat electromyography (EMG) is in the chart. Medical necessity 
for an MRI of the thoracic spine has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the chest spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest spine (72146).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx Epigenetic Molecular Assay provided on 
June 12, 2020. 
 
You asked the Plan to pay for the ConfirmMDx Epigenetic Molecular Assay. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare only covers ConfirmMDx for males who have undergone a 
previous cancer-negative prostate biopsy. The file shows that this was the enrollee's first biopsy. Based on this 
information, we decided that Medicare rules for coverage of the ConfirmMDx Epigenetic Molecular Assay 
have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx Epigenetic 
Molecular Assay provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable 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 requested device is being used in the bilevel PAP mode, rather than being used 
as a home ventilator. 
 
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 you have 
apparently done well on CPAP in the past, but the machine is not working. There is no diagnosis of COPD, 
neuromuscular disease, or thoracic restrictive disease.  Medicare does not cover a ventilator for the treatment of 
OHS. The appropriate treatment would be CPAP or BiPAP. Medicare also does not cover a ventilator when 
used as BiPAP.  The AVAPS-AE mode of support that has been ordered can be provided by certain BiPAP 
devices. However, in the absence of obstructive lung disease, this mode may not be necessary.  There has been 
no demonstration of failure of CPAP or BiPAP. A home ventilator 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services (May 25, 2020 to June 
23, 2020). 
 
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services (May 25, 2020 to June 23, 2020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Codes: 33289, C2624) 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the device is not 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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met, since the device should still be considered experimental or investigational. 
 
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 device (CPT Codes: 33289, C2624)