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

 
We decided that the Plan has to pre-approve the Freestyle Libre 14-day sensor kit 
 
You asked the Plan to pre-approve FreeStyle Libre. You say that please reconsider the initial determination for 
coverage of the Freestyle Libre system The Plan denied your request. The Plan says that the medically 
necessary criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 FreeStyle Libre. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has diabetes mellitus. The enrollee is insulin treated with 
three or more daily administrations of insulin and the enrollees insulin treatment regimen requires frequent 
adjustment by the enrollee on the basis of BGM or CGM testing results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FreeStyle Libre have been met. Therefore, we decided that the Plan has to pre-
approve the Freestyle Libre 14-day sensor kit  
 
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 FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM) sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre sensor. You say that you are requesting an appeal as the 
enrollee is legally blind and on insulin. The Plan denied your request. The Plan says the records do not show 
that the enrollee is on insulin, therefore the enrollee does not meet the criteria. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the FreeStyle Libre sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous 
glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this 
provider is out-of-network with the Plan and the needed equipment can be obtained from an in-network 
supplier. 
 
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 pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office or other outpatient visit for the evaluation and 
management of an established patient (99213) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an ophthalmology consultation. You say that you have seen this provider for 
30 years. The Plan denied your request. The Plan says necessary care can be provided in-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 
an office or other outpatient visit for the evaluation and management of an established patient (99213) to be 
provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard. 
 
You asked the Plan to pre-approve Cologuard. You say that no gastrointestinal (GI) specialists are available for 
a while, your symptoms are getting worse, and the Cologuard test could get you answers that may warrant an 
expedited emergency appointment with a GI in your area. The Plan denied your request. The Plan says this 
request for coverage of Cologuard is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service on or after October 
9, 2014, The Cologuard test is covered once every three years for Medicare beneficiaries that meet all the 
criteria listed in the Medicare rules section of this letter.  
 We looked at the file and Medicare rules. The record shows that you are only 48 years old, and are not between 
the ages of 50 and 85 years old. Based on this information, we decided that Medicare rules for coverage of 
Cologuard have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture and chiropractic services provided from 
April 14, 2022, to April 29, 2022. 
 
You asked the Plan to pay for the chiropractic care and acupuncture services. You say that your plan provides 
for 18 chiropractic visits per year. You say that your provider confirmed this with the Plan. You say that at the 
end of May, you only had 10 visits. You also say that your plan provides for 18 acupuncture visits per year and 
have not reached that number. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, your Plan offers coverage beyond the Medicare acupuncture benefit and chiropractic care benefit. As 
such, the Plans rules apply in this case. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic care and acupuncture services have not been met. Specifically, the file shows that 
the benefit for acupuncture and chiropractic services has been exhausted. The record shows that the Plan paid 
for 6 chiropractic visits from January 4, 2022, to March 21, 2022, and 12 acupuncture visits from January 4, 
2022, to March 17, 2022, thus exhausting the benefit of 18 visits per calendar year. Therefore, we decided that 
the Plan does not have to pay for the acupuncture and chiropractic services provided from April 14, 2022, to 
April 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that erythropoiesis stimulating agent (ESA)  treatment for 
the anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, 
lymphoma, and lymphocytic leukemia is only reasonable and necessary when the hemoglobin level 
immediately prior to initiation or maintenance of ESA treatment is greater than 10 g/dL (or the hematocrit is 
greater than 30%). 
 
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 Aranesp. Our reviewer says that the 
requested use of Aranesp is not supported. Our physician reviewer found there is no documentation that the 
enrollee's anemia is secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple 
myeloma, lymphoma or lymphocytic leukemia. The enrollee's hemoglobin level is also 7.3 grams/dL. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested pneumatic compression 
device is not covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 36 trip limit. 
 
You asked the Plan to pre-approve additional routine transports. You say that you need additional trips to 
ongoing medical appointments. The Plan denied your request. The Plan says this request exceeds your routine 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.   
We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that they have confirmed that 36 trips have been previously covered. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 36 trip limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3, per square centimeter (Q4158) 
application of a skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. 
cm or less wound surface area (15271) application of skin substitute graft to face, scalp, eyelids, mouth, neck, 
ears, orbits, genitalia, hands, feet, and/or multiple digits; total wound surface area up to 100 sq. cm; first 25 sq. 
cm or less wound surface area (15275). 
 
You asked the Plan to pre-approve Kerecis Omega3. You say that you are requesting authorization for both the 
product code and the application code. The Plan denied your request. The Plan says here is insufficient 
evidence that the requested service meets the reasonable and necessary standard for medical necessity. 
 
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 Kerecis Omega3. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a diagnosis of diabetes with leg wounds. Per 
the documentation the wounds are under one (1) square centimeter (cm) in size. Guideline used to decide 
medical necessity state the skin deficit must be at least one (1) square centimeter (cm) in size; and there is 
evidence of adequate circulation/oxygenation to support tissue growth and wound healing by having a clean 
granular base, an Ankle-Brachial Index (ABI) of no less than 0.60 and toe pressure greater than 30 millimeters 
of mercury (mmHg). Kerecis Omega3 is not a CCA preferred skin and soft tissue substitute, and it is not listed 
in a Medicare approved Compendia: Micromedex. The review has determined that the items/services at issue in 
this case are 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3, per square centimeter (Q4158) application of a skin substitute graft 
to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area 
(15271) application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, 
feet, and/or multiple digits; total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface 
area (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 17, 
2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit . You say that it was the facility responsibility to 
obtain authorization and services were rendered in good faith. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
  
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
February 17, 2022, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure provided on March 18, 
2022. 
 
You asked the Plan to pay for the pathology procedure. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a molecular pathology procedure provided on March 18, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 18, 2021. 
 
You asked the Plan to pay for outpatient hospital services. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for outpatient hospital services provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional months of oxygen rental (E1390, E0431). 
 
You asked the Plan to pre-approve the additional months of oxygen rental. You say that this service is 
medically necessary. The Plan denied your request. The Plan says payment for oxygen rental has already been 
exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. Payment for 36 months of oxygen rental has already been made. 
Based on this information, we decided that Medicare rules for coverage of the additional months of oxygen 
rental have not been met. Therefore, we decided that the Plan does not have to pre-approve additional months 
of oxygen rental (E1390, E0431).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transport rendered on February 19, 2021. 
 
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 that the services are not covered. 
 
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. The Plan states that the claim was not billed correctly; however, the Plan has not 
provided clear documentation of their exact denial reason or Medicare rules to support that the claim is not 
payable as billed. Therefore, we decided that the Plan has to pay for the ambulance transport rendered on 
February 19, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 29, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections (20552). 
 
You asked the Plan to pre-approve the trigger point injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the requested 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of trigger point injections (20552). have 
been met. There was no order from the physician for this service. Therefore, we decided that the Plan does not 
have to pre-approve trigger point injections (20552).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement and nail trimming provided on May 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nail debridement and nail trimming. You say that your physician has treated the 
patient with a good will and based on medical necessity. The Plan denied your request. The Plan says this 
provider and the referring provider are not network providers with the Plan. The Plan also says that they have 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nail debridement and nail trimming provided on 
May 6, 2022, by an out-of-network (OON) provider.