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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) reader device (K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day reader device. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says you do not meet prior authorization 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 14-day reader device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 14-day continuous glucose monitor (CGM) reader device (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation, procedure code 99245. 
 
You asked the Plan to pre-approve an office consultation. You say that the services are needed, or the enrollee 
will not live much longer. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99245 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99245 is not valid for Medicare purposes. The records show that this service pertains to office 
consultations to be performed as part of transplant activities. Please note, that all related services for the 
transplant were approved by the Plan separately. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99245 have not been met. 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an office consultation, procedure code 99245.
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 have painful flat 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental and 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve percutaneous electrical nerve stimulation (PENS). You say that medical 
records confirm medical necessity. The Plan denied your request. The Plan says the requested procedure does 
not meet the Medicare or health plan coverage criteria. 
 
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 percutaneous electrical nerve 
stimulation (PENS). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has tried conservative 
treatment including TENS. This procedure is considered an experimental/ investigational. It is unproven and 
not medically necessary due to insufficient evidence of 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 percutaneous electrical nerve stimulation (PENS) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2021 billed with 
codes 81220, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 14, 2021 billed with codes 81220, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335 and 
81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and partial 
mandibular dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says your benefit for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service November 15, 2018. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and 
partial mandibular dentures (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) 
receiver (K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM receiver. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says you do not meet prior authorization 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 or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Dexcom G6 CGM receiver have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) 
receiver (K0554).
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 you need to go to and IRF for therapy. The Plan 
denied your request. The Plan says that while you will likely benefit from ongoing therapy to enhance 
rehabilitation potential, there is no evidence that this cannot safely be done at a lower level of care. 
 
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. You 
are medically stable and do not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute nursing needs identified or documented. At the current functional level, you do 
not need therapy 3 hours a day, 5 days a week. While you would benefit from physical and occupational 
therapy, your rehab needs can be safely provided in an alternate and low intensity setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Denosumab injection provided on 
October 18, 2021. 
 
You asked the Plan to waive the coinsurance for the Denosumab injection. You say that you do not understand 
why the cost of this drug went from $0 to $391. The Plan denied your request. The Plan says this coinsurance 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B drugs.  
 
The enrollee has been asked to pay 20% coinsurance for the Denosumab injection. The Denosumab injection 
falls within the Medicare Part B drugs benefit category. This cost sharing applies regardless of what may have 
been charged in the past. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Denosumab 
injection provided on October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued SNF care and services. 
 
You asked the Plan to pre-approve continued SNF care and services.. You say to please provide authorization 
for continued services in the SNF to help the enrollee reach maximum function. The Plan denied your request. 
The Plan says the enrollee does not meet medically necessity criteria for daily skilled rehabilitation and nursing 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve continued SNF care and services. Our 
reviewer says that the enrollee has a past medical history of breast cancer, sleep apnea, chronic lung disease, 
hypertension, heart failure, chronic kidney disease, osteoarthritis and muscle weakness who was admitted to a 
skilled nursing facility for skilled nursing and therapy services on July 29, 2022 after treatment in an acute 
hospital for COVID-19 infection, anemia and gastrointestinal bleeding with gastric ulcers. The enrollee was 
treated in the hospital and the condition stabilized. The enrollee was weak and deconditioned and was working 
with physical and occupational therapy in the nursing facility. As of August 05, 2022 the enrollee was walking 
150 feet with a wheeled walker with distant supervision and was modified independent for transfers and was 
contact guard assist or better with activities of daily living. The enrollee otherwise was reported to be medically 
stable on outpatient medications.  
 
Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care and services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the SNF care and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI is covered when the first injection directly 
and significantly provided improvement of the condition being treated may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale* for at least three months. 
 
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 injection. Our reviewer says that the 
requested ESI is not medically reasonable and necessary. Our physician reviewer found that there is no 
documentation of the results of the prior ESI. Therefore, the procedure, at this time is deemed 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43752 billed for date of service January 23, 
2022. 
 You asked the Plan to pay for procedure code 43752. You say that the medical records support the services. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
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 43752 is a column II code to column I code 99233. 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 43752 
billed for date of service January 23, 2022.
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 you were completely independent prior to admission. 
The Plan denied your request. The Plan says that your needs can safely be met at a lower level of care. 
 
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. You 
are medically stable and do not need physical medicine and rehabilitation physician's close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. At the current functional level, you do 
not need therapy 3 hours a day, 5 days a week. While you would benefit from physical and occupational 
therapy, your rehab needs can be safely provided in an alternate and low intensity setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on January 24, 2022. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 64420 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 the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
provided on January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT) 
(D0367) provided on February 3, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that this was not related to your teeth in 
any way. You say that the issue was with your jaw joint. You also say that this should be covered as a medical 
service. The Plan denied your request. The Plan says the service is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
cone beam computed tomography (CT) (D0367) provided on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 17, 2019, 
to April 22, 2019. 
 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 the submitted records do not support the billing of DRG 871. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 these services. Our reviewer says that the submitted records do not support the 
billing of DRG 871. Our physician reviewer found the enrollee was admitted to the hospital with a diagnosis of 
chest pain and shortness of breath. There was a recent diagnosis of congestive heart failure and atrial 
fibrillation. There was no laboratory or clinical evidence of sepsis. DRG 871 was not supported in the medical 
records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from April 17, 2019, to April 22, 2019.