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

 
We decided that the Plan does not have to pre-approve the Freestyle Libre Kit 2 Sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 does not show that the enrollee's regimen 
requires frequent daily adjustments of insulin based on blood glucose testing results, or that the enrollee 
requires treatment with a continuous subcutaneous insulin infusion pump, or that the enrollee is on insulin injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre Kit 2 Sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinvanti (CPT code J0185). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has extreme nausea that is not 
controlled by Zofran or Dexamethasone. You also say that the enrollee has been on treatment with 
Aloxi/Cinvanti since October 15, 2021, and it has been very helpful in controlling their nausea while taking 
Soliris. The Plan denied your request. The Plan says this drug is not being prescribed for a medically-accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested does not meet FDA indications. May also have reversible cause as note state narrowing of 
gastric outlet that my need dilatation. Also, other treatments for nausea and vomiting have not been tried such 
as lorazepam and metoclopramide. The use is not supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cinvanti (CPT code J0185).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing, (F2 (prothrombin) gene analysis and 
F5 (coagulation factor V) gene analysis, Leiden variant) (CPT code(s): 81240 and 81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that the services are necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. The enrollee's records do not 
indicate that the enrollee is pregnant. The rules say that genetic testing for the F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients. Therefore, we decided that the Plan does not have to pre-approve the genetic 
testing, (F2 (prothrombin) gene analysis and F5 (coagulation factor V) gene analysis, Leiden variant) (CPT 
code(s): 81240 and 81241).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital services provided to the enrollee from June 12, 
2022, to June 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this can be approved as observation care only. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for acute inpatient hospital services provided to the enrollee from June 12, 2022, to June 14, 2022.  
 
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 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 documentation does not support medical necessity for admission to an IRF. You have 
no acute medical complexity and no acute rehabilitation nursing needs for an IRF admission. While you would benefit from physical and occupational therapy, your rehabilitation needs can be safely met in an alternate and 
low intensity setting such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 1, 2022, 
to July 3, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service July 1, 2022, to July 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient visit (99203) billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for a new patient visit. You say that this service was billed appropriately. The Plan 
denied your request. The Plan says this service was not coded correctly, as an established patient visit code 
should be used. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the record shows that the 
enrollee has been seen by a physician of the same specialty at the same practice within the last three years. This 
means the visit in question would be considered an established patient visit rather than a new patient visit. 
Based on this information, we decided that Medicare rules for coverage of a new patient visit have not been 
met. Therefore, we decided that the Plan does not have to pay for a new patient visit (99203) billed for date of 
service July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body; endosteal 
(D6010). 
 
You asked the Plan to pre-approve the implant. You say that you have not eaten solid food since November, 
2022 because you have no teeth and are feeling bad for this reason. The Plan denied your request. The Plan 
says based on your dentist's x-rays, notes, and pictures, your teeth are not healthy enough to support this 
service. Criteria has not been met. 
 
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. The Plan covers the implant 
when the services are medically necessary and reasonable.  
 
 
 
 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 implant. Our reviewer says that 
review of the documentation indicates that the crowns on tooth #'s 6-11 have been removed leaving implant 
crowns on tooth #'s 5 and 12 and an implant in area of tooth #11. There is no indication as to the complete 
treatment plan to restore the missing tooth #'s 7-11. A single tooth implant of tooth #6 would not be approved 
for coverage as medically reasonable and necessary until a definitive treatment plan is proposed for the 
replacement of the remaining missing teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the surgical placement of implant body; endosteal (D6010).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport provided on April 17, 2022. 
 You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that you 
are asking for a reconsideration with supporting medical records that were provided to the Plan. The Plan 
denied your request. The Plan says the enrollee's primary insurance provider had not received a claim for the 
appealed service and that a claim must be submitted to the other insurance first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
primary insurance provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be 
held responsible for the ambulance service, basic life support, emergency transport until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, emergency transport provided on April 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient office visit (99213) and fundus photography (99250) 
provided on July 27, 2022. 
 
You asked the Plan to pay for the outpatient office visit and fundus photography. You say that you are not sure 
why this claim was denied. You also say they took a picture of your eye, but did not advise that there would be 
a cost for it. The Plan denied your request. The Plan says that this claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The record shows that you received an outpatient office visit and fundus 
photography from an in-network provider. We find that these are Medicare-covered services. The Plan has not 
provided any evidence or rationale to support their denial in this case. Therefore, we decided that the Plan has 
to pay for the outpatient office visit (99213) and fundus photography (99250) provided on July 27, 2022.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services billed with procedure code 81479 for date of service 
February 21, 2022. 
 
You asked the Plan to pay for procedure code 81479. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that code 81479 is not a valid code for Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not issued a valid denial. Per Medicare, CPT code 
81479 is a valid code for laboratory services. The Plan has not forwarded sufficient evidence to support the 
denial of this code. It is the burden of the Health Plan to substantiate their denial with evidence. Therefore, we 
decided that the Plan has to pay for laboratory services billed with procedure code 81479 for date of service 
February 21, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Mvasi. 
 
You asked the Plan to pre-approve Mvasi. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says Mvasi is not medically reaosnable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Mvasi. Our reviewer says that the 
enrollee does not meet criteria for use of Mvasi. Our physician reviewer found the requested use of Mvasi is 
not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one 
of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Mvasi.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886 and 95911 provided on June 14, 
2022. 
 
You asked the Plan to pay for procedure codes 95886 and 95911. You say that the medical records support the 
billing of procedure codes 95886 and 95911. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes 95886 and 95911. 
 
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 95886 is Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The definition of code 95911 is Nerve conduction 
studies; 9-10 studies. 
 
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 procedure codes 95886 and 95911. Our reviewer says that the medical records do not support the billing of procedure codes 95886 and 95911. Our reviewer found the 
records for the date of service under review did not contain details that the services billed were provided. There 
was no electrodiagnostic testing documented as having been done on the date of service. The member was seen 
for a consult only. It's unclear if any other testing was done in the interim. However, for the date of service 
under review the records did not support performance of the CPT codes being reviewed herein. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95886 and 95911 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95886 and 95911 provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that you are currently using the 
requested sensor since March 2022 and would like to continue. The Plan denied your request. The Plan says 
you do not meet criteria for approval of the requested CGM sensor. 
 
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 use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
14-day continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for five units of procedure code 87481 provided to the enrollee on 
February 11, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary based on the patient's 
current signs and symptoms. The Plan denied your request. The Plan says that the records do not contain lab 
results to support the complete five units of Candida species detection having been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
medical records support the use of procedure code 87481 with five units. The results showing it was not 
detected are apparent in the medical records. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
five units of procedure code 87481 provided to the enrollee on February 11, 2023.  
 
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.