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

 
We decided that the Plan does not have to pre-approve the auricular percutaneous electrical nerve stimulator 
(PNS) device (L8679, 64555). 
 You asked the Plan to pre-approve the auricular PNS device. You say that you would like to provide the 
following information to support that this is not an investigational procedure. The Plan denied your request. 
The Plan says the clinical value and effectiveness of an auricular PNS device in the setting of diabetic 
neuropathy and chronic pain has not been demonstrated in the peer-reviewed literature. 
 
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 auricular PNS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental and investigational procedure. Therefore, the request 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 auricular PNS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the auricular percutaneous electrical nerve stimulator (PNS) device (L8679, 
64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and bitewings (D0274) 
provided on December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought you would receive 1 evaluation and 
x-ray each benefit year and do not understand why your benefit was exhausted. The Plan denied your request. 
The Plan says your annual maximum benefit for the year 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. On January 
18, 2022, the Plan paid $309 for dental services. On March 8, 2022, the Plan paid $72 for dental services. On 
June 21, 2022, the Plan paid $88 for dental services. On September 27, 2022, the Plan paid $97 for dental 
services. For the year of 2022 the Plan paid $500 ($309 paid + $72 paid + $88 paid + $97 paid) for dental 
services; therefore, your annual dental benefit for the year was exhausted on the date of service of September 
27, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and 
bitewings (D0274) provided on December 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine fusion and decompression services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's back pain is worsening. 
The Plan denied your request. The Plan says there is no evidence of stenosis. 
 
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 requested services. Our physician 
reviewer found that the medical records do not have imaging studies showing severe stenosis or spinal 
instability. Therefore, the requested surgery is not medically needed at this time. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spine fusion and decompression services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 15, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
November 15, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321 and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device. 
 
You asked the Plan to pre-approve the device. You say that you had surgery. You say that your doctor 
requested this stretching machine. You also say that you do not agree with this denial. The Plan denied your 
request. The Plan says the requested device is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a continuous passive motion exercise device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the provided records do 
not indicate the medical necessity or reasonableness, as defined by Medicare rules. The elements of the 
coverage criteria are not satisfied, and the requested service cannot be 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 a computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deep brain stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee's memory loss could affect treatment. 
 
The Plan follows Medicare rules. Medicare rules say that deep brain stimulation is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee's evaluation suggested cognitive impairment to a degree that it may be 
expected to interfere with the enrollees ability to benefit from DBS. At the time of his evaluation the enrollee 
was otherwise not noted to have readily been familiar with the procedure which he was being evaluated for. He 
was otherwise recommended to have a chaperone at times for other visits, which otherwise suggests 
impairment to a degree that would impair or preclude benefit from the requested device. For these reasons, the 
criteria cannot be considered to have been 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a deep brain stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve Xifaxan. You say that you have provided medical records to support your 
appeal. The Plan denied your request. The Plan says this drug is not covered under the patient's medical 
benefits. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan.  
 
Benefits for Xifaxan may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 would like inpatient rehabilitation in order to 
receive physical therapy as it is being recommended. You said that it is unsafe for you to go home because you 
are going to need IV antibiotics for a long time. You said that going to a skilled nursing facility does not help 
much as you were previously independent prior to all of your surgeries. The Plan denied your request. The Plan 
says you do not meet IRF criteria, and you can be managed 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of an infected artificial hip joint. Your medical problems are stable, and you have no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy testing. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the enrollee is at high risk of 
developing lymphedema so 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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found variable results regarding the ability of bioimpedance spectroscopy to 
measure absolute volumes as well as the observation of wide limits of variations make bioimpedance 
spectroscopy problematic for individual assessment in the clinic, particularly in populations with abnormal fluid distribution or body geometry. bioimpedance spectroscopy has been found to be more accurate for 
measure changes in fluid volumes or body cell mass, particularly in post-surgical and human 
immunodeficiency virus infected individuals. It is possible that population-specific adjustments may improve 
the accurate of bioimpedance spectroscopy may improve the accuracy of bioimpedance spectroscopy for 
assessing individuals in the clinical setting; however, additional research and development is needed before this 
method can be accepted for routine use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items are not covered. 
 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. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
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 (E0675 and E0673).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sclerotherapy and phlebectomy procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the ultrasound showed dilated varices 
in the left lower leg. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollees symptoms are improved. Although it is noted that the symptoms are not 
gone, it is not noted that the symptoms are in any way significant. Additionally, it is documented that the 
enrollee has no bulging varicosities only reticular veins and telangiectasias. In the absence of documentation of 
significant symptoms due to bulging residual varicosities, the requested services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sclerotherapy and phlebectomy procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that this medication is needed to improve 
your health. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary capsules.   
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar puncture with cerebral spinal fluid testing to 
be provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve a lumbar puncture with cerebral spinal fluid testing to be provided by the 
requested out-of-network provider. You say that due to the risks associated with a failed procedure you do not 
want an inexperienced provider to perform these services and you believe the requested provider is the most 
experienced to provide these services. The Plan denied your request. The Plan says the requested services can 
be provided safely by an in-network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a lumbar 
puncture with cerebral spinal fluid testing to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items should be covered. 
The Plan denied your request. The Plan says these are not covered items. 
 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. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
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 (E0675 and E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item would be the best treatment for the 
enrollee given their medical history. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary because there is no evidence that a the enrollee cannot use a BiPAP with AVAPS. 
 
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 a home ventilator. Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found he record indicates that the 
enrollee has chronic hypercapnic respiratory failure from severe chronic obstructive pulmonary disease. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) 
machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage 
for such a device is available upon request. 
 
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.