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

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on August 10, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
 
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 Plan argues that the proof of delivery is not itemized. However, the 
documentation contains an itemized packing slip with the same tracking number as the delivery ticket showing 
that the items in question were delivered. As the documentation shows that the items in question were 
delivered, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
electrical stimulator supplies provided on August 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral interlaminar epidural (62323). 
 
You asked the Plan to pre-approve an epidural injection. You say that the injection is needed due to your 
current back pain. The Plan denied your request. The Plan says you do not meet LCD criteria. The records do 
not show that this treatment helped your pain at least 50% previously. Thus, repeating the injection 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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have chronic low back pain from spinal stenosis and scoliosis. You have degenerative 
changes documented on MRI. You have had physical therapy, chiropractic and home exercise. You take 
Diclofenac and Gabapentin for pain. You had an epidural steroid injection but did not achieve 50% pain relief 
for 3 months. The LCD criteria to repeat an epidural steroid injection is 50% pain improvement for 3 months.  
This was not achieved and therefore, the request is deemed not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lumbar/sacral interlaminar epidural (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 continuous glucose monitor system 
 
You asked the Plan to pre-approve the Freestyle Libre Kit sensor. You say that the medical records provided 
will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee is not on insulin 
and does not meet the Medicare 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 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 Freestyle Libre KIT sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 continuous glucose 
monitor system
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for July 
1, 2022, to July 3, 2022. 
 
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 enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for July 
1, 2022, to July 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There are no pulmonary function tests to assess the severity of the chronic obstructive pulmonary 
disease (COPD), and there is no arterial blood gas (ABG) done while stable to document chronic carbon 
dioxide (CO2) retention. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average volume assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON office visit. You say that you have not received an eye exam in 
four months, and you have glaucoma. The Plan denied your request. The Plan says the requested services can 
be provided by a network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an embolizaton of the carotid artery (64624, 64626, 
75894). 
 
You asked the Plan to pre-approve an embolizaton of the carotid artery. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the request 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 an embolizaton of the carotid artery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee in this case has symptomatic carotid stenosis. However, 
the requested services are not being done for hemorrhage or to address a tumor. The request does not appear to 
meet the requirements for coverage at this time. 
 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 embolizaton of the carotid artery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an embolizaton of the carotid artery (64624, 64626, 75894).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95927 provided to the enrollee 
on April 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG), recording in coma or sleep 
 
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 95822 or CPT 95927 were rendered in this case. In terms of CPT 95822, a routine EEG was not done 
during this study. An insufficient number of EEG channels were recorded and as such the recording done does 
not meet the threshold for performance of 95822 as defined by the CPT manual. In terms of CPT 95927, the 
recording that was done is more properly reflected by the use of CPT code 95938 (which was also submitted). 
The recording was from the extremities more than the peripheral nerves, so the use of this additional CPT code 
was not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95822 and 95927 provided to the enrollee on April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the medical records do not indicate that the enrollee meets the diagnostic 
criteria of both Alzheimer's disease and frontotemporal dementia. There is no indication that the exam is being 
requested in the context of a clinical trial. The request does not meet the Medicare or health plan coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee was referred for a 
PET/CT of the brain for memory problems. This is a request for a non-oncologic purpose. According to the 
NCD, this service may be covered in enrollees who meet diagnostic criteria for both AD and FTD. However, 
the records provided for review did not support a diagnosis of either AD or FTD (let alone both). In as much 
the baseline requirement for coverage of this service is not met/satisfied at this time. The denial is 
recommended to be upheld. 
 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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation 
(78608).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that rTMS is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe recurrent 
episode major depressive disorder without psychotic features. She has not had evidence-based psychotherapy 
or standardized testing. The criteria for coverage are not met and the services are therefore not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repetitive transcranial magnetic stimulation (rTMS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve Cequa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Cequa.  
 
Benefits for Cequa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with imaging guidance (64625). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the clinical value and effectiveness of 
radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. The use of radiofrequency ablation for pain management related to 
sacroiliitis has not been shown to provide a clear long-term benefit over standard treatment for chronic 
sacroiliac joint pain. Based on this information, we decided that Medicare rules for coverage of the surgical 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation, nerves innervating the sacroiliac joint, with imaging guidance (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage under special supplemental benefit for the 
chronically ill (SSBCI). 
 
You asked the Plan to pre-approve coverage under SSBCI. You say that you received a letter of denial and you 
do not understand why because you were granted these benefits with this Plan. You have asthma and chronic 
obstructive pulmonary disease. The Plan denied your request. The Plan says there is no documentation that the 
member meets criteria. The provider returned an attestation form stating that the enrollee does not meet criteria 
for the expanded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of coverage under SSBCI have not been met. Specifically, we have confirmed that you do not have 
one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not 
have to pre-approve coverage under special supplemental benefit for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on October 2, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that there is no 
evidence to support the ordering provider is ordered the service. 
 
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 Plan argues that there is no evidence to support the ordering provider is 
ordered the service. However, the records show that the electrical stimulator and monthly supplies were 
ordered by the same provider that saw the enrollee on July 29, 2021, per the note provided. As the records 
show that the treating provider ordered the supplies, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the electrical stimulator supplies provided on October 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 11720. The Plan denied your request. The Plan says payment for 
code 11720 is bundled into payment for code 11719.  
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) (PCD) and 
appliance provided on October 4, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E0675) (PCD) and appliance provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says intensity modulated radiation therapy (IMRT) can be approved if requested. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that any potential benefit or detriment of proton therapy over standard IMRT is an investigational 
question (being pursued in randomized studies- i.e. for intermediate to low-risk prostate cancer. Whether 
proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of 
investigation and remains controversial. Particularly with the use of the SpaceOAR hydrogel spacer, the risk of 
gastrointestinal/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more 
unlikely that there would be a potential benefit from proton therapy. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.