Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remodulin. 
 
You asked the Plan to pre-approve Remodulin. 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. 
 
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 Remodulin. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no indication that the enrollee has 
tried and failed the required drug. Based on the medical records provided and the Medicare-approved major 
drug compendia there is no indication that the plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remodulin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Remodulin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM device and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre CGM device and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion and possible treatment to an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you were just made aware that 
you have cancer and are requesting that Plan approve that you seek service for oncology at this location. The 
Plan denied your request. The Plan says the services are not medically necessary because care is available 
within the Plan. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found there was no 
provided justification for the out-of-network consultation. There was no reasoning provided describing why 
you could not effectively get your second opinion from another highly qualified oncologist without leaving the Plan's network. The services are not necessary to be obtained out-of-network based on the provided 
documentation.  
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve a second opinion and possible treatment to an out-of-network 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure coded as 64628 and 64629. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you and the enrollee request this 
denial be overturned and the procedure authorized. The Plan denied your request. The Plan says this procedure 
is considered experimental and investigational. Medical studies have not proven that this service is helpful for 
the treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure coded as 64628 and 64629.
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 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. 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. The enrollee has had a functional decline 
from her baseline level of function and would likely benefit from therapy, but she does not require the intensity 
of therapies provided on acute inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TMS (CPT code(s): 90869, 90867, 90868-x34) 
 
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 requirement is: A psychiatrist (mental health doctor) has ordered this service and is 
supervising your treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the documentation submitted does not include a valid 
signature from the persons responsible for the care of the beneficiary. Furthermore, the rules say that the order 
for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the patient and 
reviewed the record. The physician will have experience in administering TMS therapy. The treatment shall be given under direct supervision of this physician (physician present in the area but does not necessarily 
personally provide the treatment). Therefore, we decided that the Plan does not have to pre-approve TMS (CPT 
code(s): 90869, 90867, 90868-x34)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 home ventilator. Our physician 
reviewer found there is no documentation of chronic carbon dioxide (CO2) retention with arterial blood gas 
(ABG) done while stable. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. This has not 
been tried and failed as an outpatient. Medicare does not cover a home ventilator when used as 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided March 1, 2021. 
 
You asked the Plan to pay for the wearable automatic external defibrillator. You say that you were having 
issues with your new reconciliation software that you were not aware of. You are requesting that the Plan 
waive the timely filing requirements. The Plan denied your request. The Plan says the claim was received past 
the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the wearable automatic external defibrillator was not filed until August 25, 
2022. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of special supplemental benefit for the 
chronically ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI services. You say that the enrollee requires the SSBCI coverage. 
The Plan denied your request. The Plan says the documentation does not support that all criteria for this benefit 
have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition who also require intensive care coordination and are at a high risk 
for hospitalization.  
 
We looked at the file and Medicare rules. Though there is documentation of a qualifying condition, the other 
criteria are not answered on the form submitted, and no records were provided despite requests to justify that 
the other criteria have been met. Therefore, we decided that the Plan does not have to pre-approve coverage of 
special supplemental benefit for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor device (E0651). 
 
You asked the Plan to pre-approve a pneumatic compressor device. You say that this treatment has been 
prescribed to treatment symptoms associated with lymphedema and should therefore be assessed using the 
NCD guidelines for lymphedema treatment, not chronic venous insufficiency. The Plan denied your request. 
The Plan says since assessments and/or progress of a four-week trial were not clearly documented in the 
customers medical record, the customer does not meet the requirements for coverage. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor device 
(E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and accessories 
(E2361, E1028, E1002, E2620, E0955, K0040, E0953, E0953, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you believe that all 
services requested are medically necessary because you are paralyzed from the waist down and need the tilting 
feature and these features are necessary to improve your quality of life. The Plan denied your request. The Plan 
says you do not meet criteria for tilt feature and therefore do not meet criteria for the base code group 3 power 
wheelchair with single power options. You are not at high risk for skin breakdown on sitting surfaces and there 
is no history of current or previous skin break down. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a group 3 power 
wheelchair can be covered if the medical necessity for a PWC is met and if the disorder causing the mobility 
limitation is a neurological condition, myopathy or congenital skeletal deformity. You also must require a drive 
control interface, power tilt or a power recline seating system and if there has been a specialty evaluation that 
was performed by a licensed/certified medical professional, such as a physical or occupational therapist. In this 
case, you have a neurologic disorder with functional deficits. The documentation does not indicate that you 
have any pressure injuries or require intermittent catheterization of the bladder that would necessitate power tilt 
or recline. The criteria for this specific power wheelchair are 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and accessories (E2361, 
E1028, E1002, E2620, E0955, K0040, E0953, E0953, E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance services coded 76937 provided on 
August 16, 2022. 
 
You asked the Plan to pay for the ultrasound guidance services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 We find that CPT code 76937 is not supported in the medical record. Specifically, this code requires ultrasound 
evaluation of potential access sites; documentation of selected vessel patency; concurrent realtime ultrasound 
visualization of vascular needle entry; and permanent recording and reporting. However, the records did not 
include documentation of an ultrasound evaluation of any of these; therefore, this code cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of the ultrasound guidance services 
have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound guidance 
services coded 76937 provided on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on July 28, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Next Generation Sequencing (NGS) to be 
covered, there must be documentation that shows the patient has decided to seek further cancer treatment (e.g., 
therapeutic chemotherapy). 
 
We looked at the file and Medicare rules. The records show the enrollee did not plan to seek further 
chemotherapy treatment. 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 (0037U) 
provided on July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnogram (sleep studies). 
 
You asked the Plan to pre-approve a polysomnogram (sleep studies). You say that a polysomnogram is 
medically necessary. The Plan denied your request. The Plan says the requested polysomnogram does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve a polysomnogram (sleep studies). Our 
reviewer says that a polysomnogram is not medically necessary in this case. Our physician reviewer found that 
a repeat split-night sleep study is not medically necessary. This enrollee has obstructive sleep apnea (OSA) and 
is using continuous positive airway pressure (CPAP) with good benefit and compliance. There have been no 
major changes in health status or body weight. The device is subject to the Phillips recall, and the enrollee is 
awaiting a replacement device, but using it to good effect. There does not appear to be any need for a repeat 
sleep study or PAP titration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a polysomnogram (sleep studies) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a polysomnogram (sleep studies).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple procedures on this 
date. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical nerve stimulator placement (63650). 
 
You asked the Plan to pre-approve the electrical nerve stimulator placement. You say that this service 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 this procedure is covered when patients have 
undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. 
 
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 electrical nerve stimulator 
placement. Our reviewer says that this service is not medically necessary. Our physician reviewer found the 
records show that the patient has a diabetic leg ulcer that is not yet healed and is a stated infection risk with the 
stimulator device placement procedure. This is a contraindication to the procedure.  
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 electrical nerve stimulator placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electrical nerve stimulator placement (63650).