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

 
We decided that the Plan does not have to pre-approve the sensor; invasive (e.g., subcutaneous), disposable, for 
use with non-durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day 
supply (A9276) and the receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor 
system (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that you suffer from diabetes and 
has been testing your glucose for the past 20 years. You are continuously checking glucose levels daily and 
need the patch to ensure glucose levels. You do not want any more pain by pricking your fingers. The Plan denied your request. The Plan says complete medical records was not received from the provider that show that 
you meet the Medicare criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the sensor; invasive (e.g., subcutaneous), 
disposable, for use with non-durable medical equipment interstitial continuous glucose monitoring system, one 
unit = 1 day supply (A9276) and the receiver (monitor), dedicated, for use with therapeutic glucose continuous 
monitor system (K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty (22856). 
 
You asked the Plan to pre-approve a total disc arthroplasty. You say that this procedure will optimize the 
enrollees potential for motion in the future. The Plan denied your request. The Plan says with the enrollee 
having facet arthroplasty, a contraindication to this disc arthroplasty, the denial is upheld as investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total disc arthroplasty. Our reviewer 
says that a total disc arthroplasty is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the imaging studies show multilevel facet degenerative joint disease, which is a 
contraindication to total disc replacement surgery. 
 
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 total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total disc arthroplasty (22856).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets all Medicare criteria for an IRF 
admission. The Plan denied your request. The Plan says an IRF 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
may have a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition. 
 
You asked the Plan to pre-approve enteral nutrition. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested enteral nutrition is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is 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 enteral nutrition. Our reviewer says that 
the documentation does not support that the requested enteral nutrition is medically reasonable or necessary. 
Our physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease (COPD). The 
documentation shows that you require tube feedings for malnutrition related to advanced chronic obstructive 
pulmonary disease (COPD). You are nothing per oral (NPO) however the documentation provided does not 
indicate that you have a permanent gastrointestinal (GI) impairment or has a disease that impairs digestion 
and/or absorption of an oral diet, directly or indirectly, by the small bowel. Therefore, you do not meet criteria 
for the requested enteral nutrition. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral nutrition have not been met. Therefore, we decided that the Plan does 
not have to pre-approve enteral nutrition.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to 
June 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to June 
10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 17000 provided on June 23, 2022. 
 
You asked the Plan to pay for procedure code 17000. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not payable. 
 
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. In this case, the Plan did not provide enough evidence to support the denial of 
payment for these services based on Medicare criteria. The Plan says in their final determination that their 
records indicate procedure code 17000 has a global surgery value of 090 on the physician fee schedule. This is 
incorrect as this code only has a 10-day global surgery value. Furthermore, none of the claims the Plan 
provided for review contain a surgical procedure code with a 90-day global surgery value that was provided on 
June 14, 2022. Therefore, we decided that the Plan has to pay for procedure code 17000 provided on June 23, 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for 
LTACH services. 
 
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 that the documentation does not support that the enrollee has a need for complex 
medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital. The enrollee can receive further care at the current acute care hospital or a lower level 
of care when deemed appropriate. 
 
 
 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 LTACH services.
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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy 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 inpatient rehabilitation facility. The enrollee can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested wheelchair with power options is not required. 
 
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 the wheelchair. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate power tilt or recline. Although criteria for a power 
wheelchair are met, the enrollee does not require the options requested in this specific 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic interface, joystick, seat lift, upgraded 
motor, upgraded electronics and the accessory bar. 
 You asked the Plan to pre-approve an electronic interface, joystick, seat lift, upgraded motor, upgraded 
electronics and the accessory bar. 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 power wheelchair accessories 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 an electronic interface, joystick, seat 
lift, upgraded motor, upgraded electronics and the accessory bar. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the E2300 seat elevator and the K0108 accessory bar are 
not medically necessary as they do not serve a primary medical purpose and is statutorily non-covered per 
Local Coverage Article Wheelchair Options/Accessories - Policy Article (A52504). The Accu Trac motor 
upgrade exceeds the enrollee's medical needs and therefore not medically necessary per Medicare criteria. An 
expandable controller (E2377) is a duplicate service as E2377 has already been approved and therefore is not 
reasonable and necessary per Medicare criteria. An Ability Drive/TOLT Technologies and associated items are 
not medically necessary per Medicare criteria as this is not proven to be safe and effective therefore this request 
is not medically necessary. The K0108 Ability drive and associated K0108 hardware and K0108 drive control 
are therefore not medically necessary. Code E2351 describes an electronic interface used with a speech 
generating device. therefore the request for the speech generating interface with code E2512 is not appropriate 
as it is miscoded per LCA A52504. 
 
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 electronic interface, joystick, seat lift, upgraded motor, upgraded electronics 
and the accessory bar have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic interface, joystick, seat lift, upgraded motor, upgraded electronics and the accessory bar.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
heart (75574). 
 
You asked the Plan to pre-approve a CTA of the heart. The Plan denied your request. The Plan says the 
requested coronary computed tomography angiography is not medically reasonable and necessary for this 
enrollee. 
 The Plan follows Medicare rules. Medicare rules say that these tests are never covered for screening, i.e., in the 
absence of signs, symptoms or disease. 
 
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 CTA of the heart. Our physician 
reviewer found there is insufficient support in the peer-reviewed literature demonstrating a significant benefit 
of CTA imaging of the heart in guiding optimal management of an asymptomatic patient. Our reviewer found 
that the clinical guidelines for the use of CTA have not been met based on review of the submitted clinical 
documentation. Our physician reviewer also found that as a result, at this time coronary CTA imaging would 
not be considered medically reasonable and necessary in this 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 CTA of the heart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic angiography (CTA) of the heart (75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve these services. You say that you have severe alopecia. The Plan denied your 
request. The Plan says the services are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service September 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Up-walker. 
 
You asked the Plan to pre-approve these services. You say that you have back pain and your doctor has been 
trying to get this walker. The Plan denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pre-approve an Up-walker.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure cuff. 
 
You asked the Plan to pre-approve a blood pressure cuff. You say that due to other general symptoms and signs 
this item is medically necessary. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure cuff.