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

 
We decided that the Plan does not have to pre-approve the Dexcom G6 CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 enrollee does not use insulin three or more times per day and the 
enrollee does not use a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Dexcom G6 CGM.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service 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 service. 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 is experimental. More research is needed. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept 
procedure (CPT code 64628).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (code 98941) provided 
on July 1, 2022. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the procedure should be 
paid. The Plan denied your request. The Plan says the manipulative treatment was not for correction of 
subluxation; therefore, the service was not medically necessary. The Plan must follow Medicare rules. Medicare rules say that chiropractic manipulative treatment is covered 
only when it is 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 pay for the chiropractic manipulative treatment. Our 
reviewer says that the chiropractic manipulative treatment is not medically necessary. Our physician reviewer 
found that the enrollee has listed diagnoses of cervicobrachial syndrome, another spondylosis with myelopathy 
of the thoracic region, other spondylosis with myelopathy of the lumbar region, and sprain of sacroiliac joint. 
The enrollee complained of neck pain and low back pain. The case file does not contain documentation of 
subluxation demonstrated by x-ray or physical exam. 
 
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 chiropractic manipulative treatment have not been met. Therefore, we 
decided that the Plan does not have to pay for chiropractic manipulative treatment (code 98941) provided on 
July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of injection provided to the enrollee on June 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not send in documentation of a unique circumstance to consider the additional 
level. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the third level exceeds utilization criteria, and no extraordinary circumstances were documented. 
Therefore, the third level is deemed not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a third level of injection provided to the enrollee on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a spinal distraction device and Superion 
interspinous spacer. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this spacer is experimental. More research is needed. 
 
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 the insertion of a spinal distraction device and Superion interspinous spacer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax, low 
dose for lung cancer screening (71271). 
 You asked the Plan to pre-approve a CT scan of the thorax. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the request cannot be approved 
because the enrollee must be between 50-77 years of age. The enrollee does not meet criteria for approval of 
this CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the thorax have not been met. Specifically, the enrollee must be between 50  77 
years of age. The enrollee is not between the age of 50  77 years of age, therefore, she does not meet 
eligibility criteria for the requested CT scan of the thorax. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomography (CT) scan of the thorax, low dose for lung cancer screening (71271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that the home ventilator is necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in intelligent volume assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a home ventilator. Our Medical Director states that the documentation in the medical record does not support that the ventilator at issue is medically necessary and reasonable for you. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator.
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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous and as the enrollee is not yet stable for transfer. Completion of treatment at the 
current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you could need to have another toe amputate or 
even the entire foot. You say you do not want this to happen due to lack of proper support. You say that you 
need the foot orthotics to protect your feet. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist device (E0986). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the evaluating professional in this request did not find this to be medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a push-rim activated power assist device (E0986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 billed for date of service March 29, 
2021. 
 
You asked the Plan to pay for procedure code 95908. The Plan denied your request. The Plan says payment for 
code 95908 is bundled into payment for code 95870. 
 
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 95908 
is a column II code to column I code 95870 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95908 billed for date of service March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480, 83789-59) provided on July 12, 2022. 
 You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. In addition, procedure code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug 
testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. In addition, we find that the 
testing described by procedure code 83789 is not separately payable. Therefore, we decided that the Plan does 
not have to pay for lab services (G0480, 83789-59) provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the requested items are 
medically necessary. You say that the enrollee potentially has symptoms of hyper/hypoglycemia without being 
able to check blood sugar. You say that the enrollee drives for 6 or more hours a day, and it is not safe to 
perform fingerpricks while operating a motor vehicle. The Plan denied your request. The Plan says the criteria 
for coverage 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Moh's surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically indicated, and there are other treatment options available. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this surgery can be approved for basal cell carcinoma of the nose. It is not reasonable to delay this 
request for two months. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Moh's surgery.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified, amplified probe technique, each organism (87798) provided on May 
11, 2022. 
 
You asked the Plan to pay for the polymerase chain reaction (PCR) testing provided on May 11, 2022. You say 
that these services were medically necessary. The Plan denied your request. The Plan says PCR testing is not 
indicated as the following are appropriate means to verify fungal infection. 
 
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 pay for the polymerase chain reaction (PCR) testing 
provided on May 11, 2022. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that typically testing is not needed for 
diagnosis as clinical presentation and physical examination is often sufficient for diagnosis and the provided 
documentation did not suggest a confusion presentation or atypical physical findings to warrant testing. Also, 
standard of care testing includes direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin, and the documentation 
did not suggest any contraindications for all of these testing options to justify PCR testing. Therefore, the PCR 
infectious agent detection will be considered 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 polymerase chain reaction (PCR) testing provided on May 11, 2022. have 
not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by 
nucleic acid (DNA or RNA); Candida species, amplified probe technique (87481) and infectious agent 
detection by nucleic acid (DNA or RNA), not otherwise specified, amplified probe technique, each organism 
(87798) provided on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colonoscopy, flexible; diagnostic, including collection 
of specimen(s) by brushing or washing, when performed (separate procedure) (CPT code 45378). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is experiencing rectal pain and 
bleeding has a family history of colon cancer. The Plan denied your request. The Plan says your request is not 
medically necessary because the enrollee's records show they do not have Hematochezia not thought to be from 
rectum or perianal source and melena of unknown origin. 
 
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 service. Our physician reviewer 
found the record provided is insufficient to establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-
approve colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when 
performed (separate procedure) (CPT code 45378).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87150 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 We find that CPT code 87150 is not supported in the medical record. Specifically, there is no documentation of 
organism culture and typing by nucleic acid probe. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on July 12, 2022.