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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 76642. 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 76642 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 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation (64582, C1778, C1787, 
C1767). 
 
You asked the Plan to pre-approve hypoglossal nerve stimulation. You say that the procedure is medically 
necessary due to obstructive sleep apnea. The Plan denied your request. The Plan says you had a complete 
anteroposterior collapse of the soft palate and lateral wall squeeze. The guideline indicates it must be stated that 
there is confirmed absence of complete concentric collapse at the soft palate level by a drug-induced sleep 
endoscopy procedure. The request has been denied as the guideline criteria 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 hypoglossal nerve stimulation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found HNS is considered reasonable and necessary for the treatment of moderate 
to severe obstructive sleep apnea when there is confirmed absence of complete concentric collapse at the soft 
palate level by a drug-induced sleep endoscopy procedure. The drug-induced sleep endoscopy study on 
11/23/2022 demonstrated complete AP soft palate collapse. overage criteria not 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 hypoglossal nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve hypoglossal nerve stimulation (64582, C1778, C1787, C1767).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the out-of-network physical therapy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the services are not emergent. There are network 
providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arikayce Suspension. 
 
You asked the Plan to pre-approve Arikayce Suspension. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the requested drug is not covered under Medicare Part B. 
 
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 Arikayce Suspension.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation (D0364), intraoral 
- periapical first radiographic image (D0220 x2), occlusal adjustment - limited (D9951), incomplete endodontic 
therapy; (D3332), and limited oral evaluation - problem focused (D0140) provided on October 3, 2022 and 
October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you referred to the Plan's website to view your 
profile. You also say you are still due to have two oral exams, one bitewing and panorex, one full mouth and 
panoramic x-ray, no intraoral, and two cleanings this year. The Plan denied your request. The Plan says the 
denial is correct because these services are not covered by the Plans dental benefits or they are covered but the 
coverage benefit has 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 intraoral - periapical first radiographic image (D0220), was exhausted on date of 
service January 25, 2022. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical 
first radiographic image (D0220 x2). The Plans dental benefits do not include coverage for the cone beam CT 
capture and interpretation (D0364), occlusal adjustment - limited (D9951), incomplete endodontic therapy; 
(D3332), and limited oral evaluation - problem focused (D0140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (power scooter). 
 
You asked the Plan to pre-approve power scooter. You say that this is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for the requested power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve power scooter. Our reviewer says that 
you do not meet criteria for the requested power scooter. Our physician reviewer found the records do not show 
that you have a personal mobility deficit that impairs participation in mobility-related activities of daily living 
(MRADLs) such as toileting, feeding, grooming, and bathing in customary locations in the home. There is no 
documentation that your mobility deficit cannot be helped by use of a walker, cane, or manual wheelchair. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility device (power scooter).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitors (CGM) 
sensor (95250). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee was diagnosed 
with type 2 diabetes and although she is not on an insulin regimen, you are requesting reconsideration. The 
enrollee has difficulty obtaining reliable blood sugar values. The Plan denied your request. The Plan says the 
enrollee does 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 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 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitors (CGM) sensor (95250).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while the enrollee is being assessed 
for possible atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine. 
 
You asked the Plan to pre-approve Cyclosporine. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says they do not administer pharmacy benefits for the 
enrollee. The Plan says that the requested drug is self-administered and does not fall under Part B coverage. 
 
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 Cyclosporine.  
 
Benefits for Cyclosporine 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: 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 stable and suitable for transfer to an 
acute inpatient rehabilitation hospital to improve in a reasonable amount of time and discharge home. The Plan 
denied your request. The Plan says the Inpatient Rehabilitation Facility 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83540 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 83540. You say that this service was reasonable and necessary. 
The Plan denied your request. The Plan says this service was billed with a diagnosis code which does not 
support the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that there are certain diagnosis codes which support the medical necessity of code 83540. 
 
We find that CPT code 83540 is not supported in the medical record. Specifically, this service was not billed 
with a diagnosis code which supports medical necessity of this service. Based on this information, we decided that Medicare rules for coverage of procedure code 83540 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 83540 billed for date of service July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy as soon as possible. The Plan 
denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have complex nursing or rehabilitation needs. 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 you 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the duration of a single full-length episode of home 
health services is 60 days. 
 
We looked at the file and Medicare rules. The file shows that there was not a 60 day gap between the enrollee's 
last covered home health episode and the date of service at issue. 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 pay for the home health services rendered on April 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 2, 2022, 
August 20, 2022, and August 27, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says there is no referring provider.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on August 2, 2022, August 20, 2022, and August 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery charger (E2366). 
 
You asked the Plan to pre-approve a battery charger. You say that you need this item. The Plan denied your 
request. The Plan says the battery charger is included in the wheelchair base and is not separately approvable. 
 
The Plan must follow Medicare rules. Medicare rules say that a battery charger (E2366, E2367) is included in 
the allowance for a power wheelchair base.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a battery charger have not been met. Specifically, that the battery charger is included in the 
wheelchair base and is not separately approvable. Therefore, we decided that the Plan does not have to pre-
approve a battery charger (E2366).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the records provided support the need 
for a CardioMEMs device. The Plan denied your request. The Plan says there is not enough evidence showing 
that the requested device would improve outcomes for the enrollee's condition. 
 
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 device. Our reviewer 
says that a CardioMEMs device is 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 patients 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg with a microprocessor knee and K3 foot 
coded as L5828, L5856, L5859, L5920, L5848, L5845, L5987 and L5984. 
 
You asked the Plan to pre-approve the prosthetic leg with a microprocessor knee and K3 foot. You say that it is 
apparent that the medical records provided do clearly document all of the required criteria that are being 
provided as the reasons for the denial of coverage. The Plan denied your request. The Plan says the requested 
prosthesis exceeds the enrollee's need. that the notes do not support allegation that member is K3 ambulator 
and needs can be met with mechanical knee. 
 
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 prosthetic leg with a microprocessor 
knee and K3 foot. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested microprocessor knee and K3 foot 
exceeds the enrollee's medical need as the physician documentation is inconsistent that the enrollee is a K3 
level. The documentation indicates a history of fatigue, body pan, weakness, poor left hip range of motion and 
the need for the use of an assistive device (canes) while ambulating. The documentation does not support that 
the enrollee is a K3 level ambulator. 
 
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 prosthetic leg with a microprocessor knee and K3 foot 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic leg with a 
microprocessor knee and K3 foot coded as L5828, L5856, L5859, L5920, L5848, L5845, L5987 and L5984.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health aide services. You say that due to your age you are no 
longer in a position to do things in your home. You also say that you can hardly bathe yourself or prepare your 
food, as well as lack of eyesight. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found you 
do not have documented skilled nursing or skilled therapy needs. The requested services are not medically 
necessary or reasonable.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.