Persius/hicric huggingface dataset:
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement foot prosthesis (L5301, L5981, L5620). 
 
You asked the Plan to pre-approve the replacement foot prosthesis. You say that the replacement foot with K3 
features is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that no more than two of the same socket inserts are 
allowed per individual prosthesis. The rules also state that a replacement is only covered when there is a change 
in the physiological condition of the patient or irreparable damage. Supplier produced records are deemed not 
to be part of a medical record for Medicare payment purposes. 
 
We looked at the file and Medicare rules. An additional socket is non-covered. Two sockets have already been 
approved. The replacement foot does not meet coverage criteria. The enrollee's existing foot is under existing 
warranty for repair, and the records provided to support the replacement were produced by the supplier. Based 
on this information, we decided that Medicare rules for coverage of the replacement foot prosthesis have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a replacement foot prosthesis 
(L5301, L5981, L5620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided to the enrollee on June 10, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 services (99214) provided to the enrollee on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87150, 87641) provided on September 22, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 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 87150 
is a column II code to column I code 87500. We have also confirmed that code 87641 is a column II code to 
column I code 87150. 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 the services (87150, 87641) provided on September 22, 2021.
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 the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 this procedure is experimental and more research is needed to show its efficacy and 
safety on the patients diagnosis. 
 
 
 
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX injections, 5 over a 6 month period. 
 
You asked the Plan to pre-approve Supartz FX. You say that the preferred alternatives are not FDA-approved 
for osteoarthritis of the shoulder. You also say that the requested drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz FX. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The reviewer found that the record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's 
preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX injections, 5 over a 6 month period.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36245) provided on October 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 36245 
is a column II code to column I code 36246. 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 the services (36245) provided on October 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says the 
planned Left Reverse Total Shoulder Arthroplasty (23472) is not listed on the Centers for Medicare & 
Medicaid Services (CMS) Inpatient Only List, and is currently approved as an ambulatory procedure. The Plan 
also says that there is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found plans for a left total arthroplasty procedure are being made. Our reviewer found that 
this is a request for inpatient services following the procedure. Our physician reviewer also found that the 
patient's documented history and current medical problems suggest he is stable and would not likely require 
hospital services that would likely cross 2 midnights for this typically ambulatory procedure. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 3, 
2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer placement surgery. 
 
You asked the Plan to pre-approve the Superion interspinous spacer placement surgery. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service 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 Superion interspinous spacer 
placement surgery. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental and more research is 
needed to show the safety and efficacy of this service for your diagnosis. 
 
 
 
 
 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 Superion interspinous spacer placement surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer placement 
surgery.
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 to get back to the independence you 
had prior to your hospitalization. The Plan denied your request. The Plan says the requested admission 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 the provided documentation does not indicate that the enrollee has complex 
nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-shaped protective cover, below knee (L5704). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this request 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no clinical documentation to support the need of a custom protective cover. There is no 
supporting information, such as a need for protection from an atypical or harsh environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom-shaped protective cover, below knee (L5704).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 enrollee has multiple comorbidities that may benefit from close medical 
supervision per clinical documentation. However, evaluating therapists document that the enrollee would likely be unable to tolerate intense therapy and recommend ongoing therapy in a subacute setting. Care in an IRF 
setting is not medically 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fusion for the neck and lower back with the dtrax 
system. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary due to insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the dtrax device/system is experimental for posterior cervical fusion. More research is needed to show 
safety and efficacy of dtrax. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fusion for the neck and lower back with the dtrax system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a placement of a subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve a placement of a subcutaneous cardiac rhythm monitor. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for the requested service have 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 placement of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has no history of atrial fibrillation nor 
were any significant cardiac arrhythmias noted on electrocardiographic monitoring. A recent randomized 
clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with 
oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or 
systemic embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. 
At this time, insertion of an ILR would not be considered medically appropriate and necessary in the enrollee's 
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 placement of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a placement of a subcutaneous cardiac 
rhythm monitor (33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole 40 mg tablet. 
 
You asked the Plan to pre-approve Pantoprazole. You say that this drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical 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 Pantoprazole 40 mg tablet.  
 
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.