Persius/hicric huggingface dataset:
Appeal type: Surgery
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. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested Intracept 
procedure is considered experimental/investigational. 
 
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 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 before coverage can 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided 
December 21, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been 
met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) 
provided December 21, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for C 5 spinous process fracture after a fall and a carotid endarterectomy. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
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 pre-approve dialysis procedures to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis procedures. You say that you wish to continue being treated at this 
facility because you are in the municipality where you reside. You also say that your doctor does not attend the 
assigned facility, and he has been your provider for years. You also say that you would have to be treated by a 
new provider who does not know about your health conditions. The Plan denied your request. The Plan says 
they have coordinated with the provider to transition you to a facility that is closer to your house. The Plan also 
says that proximity and location of the contracted facility is adequate. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dialysis procedures to be provided by an out-
of-network (OON) provider.
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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can be treated at the current hospital. 
 
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 the enrollee appears to be currently unstable with new diarrhea that needs to be 
investigated and treated. The enrollee requires additional acute care hospital services that can safely be 
completed at the current facility until a lower level of care is appropriate. 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
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 a FreeStyle Libre CGM. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 21470 and 21465 billed on August 13, 
2021. 
 
You asked the Plan to pay for procedure codes 21470 and 21465. You say that procedure codes 21470 and 
21465 were not covered and the claim should be re-evaluated. The Plan denied your request. The Plan says one 
unit of code 21470 has been overturned. The Plan also says an appropriate modifier was not billed with 
procedure code 21465. 
 
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. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the MUE for CPT code 21470 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 
remaining unit of procedure code 21470 have not been met. In addition, we have confirmed that code 21465 is 
a column II code to column I code 21470. Procedure code 21465 has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria for procedure code 21465 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 21470 and 
21465 billed on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for pain and problems with self-care after an above the knee amputation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does 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 this enrollee 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. At this time, the Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative evaluation 
of coronary calcium (75571). 
 
You asked the Plan to pre-approve computed tomography (CT) with quantitative evaluation of coronary 
calcium (75571). You say that you would like the Plan to reconsider their denial. The Plan denied your request. 
The Plan says the requested service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. The requested service is not covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the cardiac CT with calcium scoring have not 
been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative 
evaluation of coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you need these stockings to treat 
your lymphedema to prevent you from getting to stage four. The Plan denied your request. The Plan says 
compression stockings are not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess. 
 
You asked the Plan to pre-approve Linzess. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Linzess.  
 
Benefits for Linzess 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. 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. 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 a CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve healthy groceries. 
 
You asked the Plan to pre-approve healthy groceries. You say that you would like the Plan's denial to be 
reversed. The Plan denied your request. The Plan says attempts were made to reach your health care provider, 
but confirmation was not received of you having a chronic condition and that the chronic condition could be 
made worse by not having or would benefit from receiving assistance with healthy groceries. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of healthy groceries. have been met. 
Confirmation of you having a covered chronic condition was not provided. The Plan made multiple requests for 
this information, but it was not provided. Without this information we cannot determine that this request meets 
coverage criteria. Therefore, we decided that the Plan does not have to pre-approve healthy groceries.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 14 personal care assistant (PCA) hours per 
week. 
 
You asked the Plan to pre-approve additional PCA hours. You say that the additional 14 hours are medically 
necessary. The Plan denied your request. The Plan says PCA services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional PCA hours have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve an 
additional 14 personal care assistant (PCA) hours per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that there are no dental providers within a 50-
mile radius of your zip code that are accepting new patients. The Plan denied your request. The Plan says your 
needs can be met in-network, and going OON is not medically necessary at this time. The Plan also says there 
are 46 in-network providers within a 50-mile radius of your zip code. 
 
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, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be rendered by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insulin for use in the Omnipod DASH disposable pump 
system. 
 
You asked the Plan to pre-approve the insulin for use with the Omnipod device. You say that this is medically 
necessary and should be approved. The Plan denied your request. The Plan says this is not medically necessary 
due to lack of documentation of fasting c-peptide levels or beta cell autoantibody status. 
 
The Plan must follow Medicare rules. Medicare rules say that insulin dispensed through a disposable drug 
delivery system is noncovered by Medicare Part B.  
 
We looked at the file and Medicare rules. Though the Plan indicated a medical necessity denial, review of the 
file shows that this specific drug delivery system is not covered by Medicare Part B. Based on this information, 
we decided that Medicare rules for coverage of the insulin for use with the Omnipod device have not been met. Therefore, we decided that the Plan does not have to pre-approve insulin for use in the Omnipod DASH 
disposable pump system.  
 
Benefits for the insulin for use with the Omnipod device may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.