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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitors 
(CGM) reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM reader. You say that you are requesting the 
Freestyle Libre 14-day reader to help with the enrollees type II diabetes. The Plan denied your request. The 
Plan says the enrollee does not meet prior authorization criteria. 
 
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 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 14-day CGM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 14-day continuous glucose monitors (CGM) reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #29 (D2950) provided on April 16, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you have a $3,000 dental benefit and should not 
have to pay for this. 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 date of service December 2, 2021. 
Therefore, we decided that the Plan does not have to pay for core build up on tooth #29 (D2950) provided on 
April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit 
provided on February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept Intraosseous Nerve Ablation. 
 
You asked the Plan to pre-approve Intracept Intraosseous Nerve Ablation. You say that Intracept 
Intraosseous Nerve Ablation is medically necessary. The Plan denied your request. The Plan says Intracept 
Intraosseous Nerve Ablation 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 Intracept Intraosseous Nerve 
Ablation. Our reviewer says that Intracept Intraosseous Nerve Ablation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure targets the 
basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this 
type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific 
literature comparing stand-alone use of Intracept device to established surgical decompression are needed.  
Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an 
alternative to standard surgical treatment. The review has determined that the requested Intracept procedure is 
not medically reasonable or necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept Intraosseous Nerve Ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Intracept Intraosseous Nerve Ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the injection is medically needed. The Plan 
denied your request. The Plan says the requested use is not an approved condition. 
 
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 Synvisc One. Our physician reviewer 
found that you have right knee pain and "mild arthritis" on plain radiographic imaging. A magnetic resonance 
imaging (MRI) scan of the right knee has been ordered to rule out other underlying pathology such as a fracture 
as your pain is reported to be out of proportion to the radiographic findings. The results of the magnetic 
resonance scan are not provided. The requested use of Synvisc One is not FDA-approved if your diagnosis is 
an occult fracture. Results of the MRI are required to rule this out. The requested use of Synvisc One is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. The documentation does not support that the requested drug is safe and effective and otherwise 
reasonable and necessary in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were told this would only be 
a $15 copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay $30 copayment for urgent care visit. Urgent care visits fall within the Urgently 
Needed Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care visit 
provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a health club membership. 
 
You asked the Plan to pay an additional amount for a health club membership. You say that this should be part 
of your benefit. The Plan denied your request. The Plan says they paid the maximum wellness allowance of 
$150, and you are responsible for any charges in excess of the limit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $150.  
 
The Plans rules for coverage of gym benefits have not been met because they have paid the maximum 
wellness allowance of $150, and you are responsible for any charges in excess of the limit. Therefore, we 
decided that the Plan does not have to pay an additional amount for a health club membership.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care due to fractures of 
pelvis. The Plan denied your request. The Plan says that based on Medicare guidelines, the request for IRF 
services does not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has multiple comorbidities that would benefit 
from close medical supervision on an inpatient basis. Clinical documentation shows that the enrollee has 
functional impairments involving two disciplines of therapy and evaluating therapist recommend intense 
therapy thus criteria for IRF have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on September 
28, 2021. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this visit should be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
 
You have been asked to pay $20 copayment for medical eye exam. Medical eye exams fall within the Vision 
Care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for medical eye exam provided on 
September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy services coded 52332 provided on 
March 22, 2022.  
You asked the Plan to pay for the cystourethroscopy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 52332 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 
cystourethroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
cystourethroscopy services coded 52332 provided on March 22, 2022.
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 enrollee is weak and not mentally or physical 
ready to be home. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
IRF services do not meet the requirements for approval. 
 
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 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 16, 2021 billed 
with codes 81479, 81408, 81407, 81406, 81404, and 81325. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 16, 2021 billed with codes 81479, 81408, 81407, 81406, 81404, and 81325.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that it should be covered since it was a follow-up to an 
approved surgery on February 4, 2022. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 an office visit provided on April 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect test (0012M) provided February 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the evidence supporting the 
use of Cxbladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says this service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. CxBladder Detect (0012M) is not an approved test with Palmetto 
GBA and has not been evaluated by the MolDx Programs technical assessment process. 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 Cxbladder Detect test (0012M) provided February 
4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) (Fluoroscopy or CT) lumbar or sacral, single facet joint (64635) destruction by neurolytic agent, 
paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT) lumbar or sacral, each additional 
facet joint (List separately in addition to code for primary procedure) (64636). 
 
You asked the Plan to pre-approve facet joint interventions for pain management. You say that that you have 
few options to improve the enrollee's pain and you feel that an RFA procedure will be of significant benefit. 
The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria listed 
in LCD L38803. 
 
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 facet joint interventions for pain 
management. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has multiple pain generators documented and 
therefore does not meet the LCD criteria. The request is deemed 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 facet joint interventions for pain management have not been met. Therefore, we 
decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) (Fluoroscopy or CT) lumbar or sacral, single facet joint (64635) destruction by neurolytic agent, 
paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT) lumbar or sacral, each additional 
facet joint (List separately in addition to code for primary procedure) (64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 22, 2021, billed 
with codes 81206, 81210, 81235, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 22, 2021, billed with codes 81206, 81210, 81235, and 81272.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on March 10, 2022, by an 
out-of-network (OON) provider.