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

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET) 
scan; metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
Disease (AD) and Frontotemporal Dementia (FTD). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee does not meet 
diagnostic criteria for both Alzheimers Disease or Frontotemporal Dementia. As such, this request does not 
meet Medicare requirements for coverage of this service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET) scan; metabolic evaluation (78608).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this has been approved under Part D as the pharmacy is dispensing the drug. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gamunex-C.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve a repeat injection. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for 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 a repeat injection. Our reviewer says 
that a repeat injection is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee had at least 50% pain relief for 3 months. Therefore, the reviewer found that 
a repeat injection is 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 a repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) (62321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for muscle transfer, any type, shoulder or upper arm; multiple 
provided to the enrollee on August 1, 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 this code is not supported in the medical records submitted. 
 
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 23397 is "Muscle transfer, any type, shoulder or upper 
arm; multiple." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
a left comminuted proximal humerus fracture. She underwent a reverse total shoulder arthroplasty with transfer 
of rotator cuff to implant on 8/1/22. However, the procedure details cite that once the implant was impacted 
into place, the implant base sutures were shuttled through the greater and lesser tuberosities and rotator cuff tendons as appropriate. Fluoroscopic imaging was utilized as necessary to confirm placement. The cerclage 
tails were then secured from an inferior to superior direction through the subscapularis and the rotator cuff 
tendons posteriorly to include supraspinatus if possible and provided vertical stability through a triangular 
formation. This corroborates that the cerclage tails and the rotator cuff tendons were secured to the implant. 
This does not support actual multiple muscle transfers as separate from the overall procedure. Therefore, the 
records do not support that CPT 23397: muscle transfer, any type, shoulder or upper arm; multiple- was 
rendered in this case. 
 
We looked at this coder'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 muscle transfer, any type, shoulder or upper arm; multiple provided to the enrollee on August 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not use insulin 3 or more times per day. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 10, 2022, to August 8, 2022. 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualified for SNF coverage. The enrollee did not have 
documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled 
services are not shown to have been required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs were custodial and could, as a practical matter, be provided 
at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from July 10, 2022, to August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records confirm that you are not homebound. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you are 
not shown to be homebound. You are not shown to have an acute illness or injury. You do not have any 
documented skilled nursing or skilled therapy needs. As such, the requested home health services, including 
associated home health aide services, are not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Prodigy Autocode blood glucose monitoring system 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it has not been demonstrated that it is medically necessary to make a specific brand 
exception. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 system. Our reviewer says that the 
requested system is considered medically reasonable and necessary in this case. Our physician reviewer found 
that due to low vision, a talking glucometer is medically necessary for this patient. This system would be used 
to help enable the enrollee to know his blood glucose levels which is required to adjust insulin doses and avoid 
low blood glucose levels. The enrollee has trouble seeing the blood glucose reading on a standard glucometer. 
 
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 system have been met. Therefore, we decided that the Plan has to pre-
approve the Prodigy Autocode blood glucose monitoring system  
 
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: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the enrollee is experiencing pain 
in their legs and feet. The Plan denied your request. The Plan says that this request does not meet the Medicare 
or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
physician reviewer found the enrollee has a history of degenerative spondylolisthesis at L4-5 demonstrated on 
prior MRI. Of concern is a history of mild instability with extension on x-rays noted in the past. Our reviewer 
found that the fact this enrollee has sustained a recent Manual Vacuum Aspiration, has experienced aggravated 
symptoms, and has a history of degenerative instability provides a valid indication for an MRI as this point 
even without a 6-week trial of physical therapy. Our physician reviewer also found that the exam should be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies. 
 
You asked the Plan to pre-approve Omnipod Dash Mis Pods. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested pods are not a covered benefit under the Part B (medical) 
plan. This is a Part D item, and the enrollee does not have Part D benefit administered by this Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The supplies requested here are not among the types which are covered by Medicare Part 
B. Specifically, the enrollee can fill the requested supplies through his pharmacy or drug plan. Therefore, we 
decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery (K0108), expandable controller, expandable 
controller harness, electronic connection device, attendant control, and power seat elevation feature for a power 
wheelchair. 
 
You asked the Plan to pre-approve power wheelchair components. You say that this is medically necessary. 
The Plan denied your request. The Plan says these components are not medically necessary or are not covered 
by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that an attendant control is not covered if provided in addition to 
a beneficiary-operated drive control. Medicare rules also say that a power seat elevation feature is not covered 
by Medicare. 
 
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 power wheelchair components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records indicate that the enrollee has 4/5 bilateral upper 
extremity strength and is independent with grooming and hygiene, thus indicating adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. Code K0108 is 
miscoding for a battery and should not be used for equipment that has a more specific code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a battery (K0108), expandable controller, expandable controller harness, 
electronic connection device, attendant control, and power seat elevation feature for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0210) provided on May 12, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you did not know that there was a frequency 
limit. The Plan denied your request. The Plan says your benefit for the requested item or service 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 item or service was exhausted on the date of service of May 12, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral radiographic images (D0210) provided 
on May 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a PET scan 
 
You asked the Plan to pay for the PET Scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they do not meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the PET Scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the enrollee is high risk for metastatic 
disease and has Gleason 8 (4+5) prostate cancer.  The NCCN current guidelines support the use of PMSA 
PET/CT in such cases in lieu of a battery of conventional imaging tests in such high-risk patients.  The use of 
Pylarify has been approved by the FDA and is the current agent of choice for such evaluation prior to treatment 
in order to rule out local and distant metastatic disease.  Requested exam should be approved. 
 
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 PET Scan have been met. Therefore, we decided that the Plan has to pay for 
a PET scan  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the admission to 
an IRF is not medically necessary. 
 
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 that you do not have the motivation or cognitive capacity for intensive rehabilitation. 
 
 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 IRF admission and services.