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

 
We decided that the Plan does not have to pay for procedure code 99316 billed for date of service August 14, 
2022. 
 
You asked the Plan to pay for procedure code 99316. You say that these were separate services. The Plan 
denied your request. The Plan says payment for code 99316 is bundled into payment for code 99223. 
 
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 99316 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not payable. 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 99316 billed for date of service August 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin and Paclitaxel protein-bound. 
 
You asked the Plan to pre-approve the requested drugs. You say that the enrollee has tried gabapentin but did 
not like the side effects. The Plan denied your request. The Plan says the drug combination is not supported for 
the enrollee's type of cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician 
reviewer found that the enrollee has a diagnosis of stage IIIc1 carcinosarcoma of the uterus. The FDA has not 
stated that the requested drug regimen is indicated for the enrollee's condition.  The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug regimen in the enrollee's clinical situation. No literature from Medicare approved cancer journals were 
submitted for review. The elements of the coverage criteria are not satisfied. Therefore, the requested service 
cannot be recommended. 
 
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 requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Carboplatin and Paclitaxel protein-bound.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device (22869, 
22870, C1821). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that per the enrollee's treating physician, the 
enrollee meets the medical necessity outlined in the criteria. The Plan denied your request. The Plan says there 
are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental in spine surgery. More research is needed. 
 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex Superion interspinous spacer device (22869, 22870, C1821).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says there are not enough studies 
on Intracept to show it is safe and effective. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MRI shows lumbar spinal stenosis which may be a cause of the back pain. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM). The Plan denied your request. The 
Plan says the enrollee does not require insulin three or more times daily. 
 
 
 
 
 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. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this due to 
worsening heart failure. The Plan denied your request. The Plan says the record does not show the enrollee has 
Class III heart failure or a body-mass index (BMI) less than 35. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are 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 to establish the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you would like to continue care with this 
provider. The Plan denied your request. The Plan says services are available with a participating 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for the Watchman procedure. 
 
You asked the Plan to pre-approve inpatient admission for the Watchman procedure. You did not provide a 
specific argument with your appeal request. The Plan denied your request. The Plan says inpatient admission 
for the Watchman procedure is not medically necessary. The patient does not have a complicated medical 
condition and this procedure can be performed at an outpatient/observation level of care. 
 
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 inpatient admission for the Watchman 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the patient had a rectus sheath hematoma at a time when 
the prothrombin time on warfarin was elevated at 4.6; however, documentation does not reveal an apparent contraindication to anticoagulation.  As such, guidelines would not support implantation of a Watchman device 
in the inpatient setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for the Watchman procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient admission for the Watchman procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that it is hard for you to get in your tub to 
shower. You say that you have fallen five to six times and have injured yourself. You also say that having a 
walk-in shower would help you with personal care. 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 for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography study (sleep study). 
 
You asked the Plan to pre-approve sleep study. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for this test. 
 
The Plan follows Medicare rules. Medicare rules state that follow-up polysomnography and sleep studies are 
not routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP 
treatment. 
 
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 sleep study. Our reviewer says that the 
enrollee does not meet criteria for this testing. Our physician reviewer found a repeat sleep study is not needed 
for the replacement of a continuous positive airway pressure (CPAP) device. The enrollee only needs an in-
person evaluation by the treating physician. The enrollee also does not meet any other criteria that would 
warrant a repeat sleep study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a polysomnography study (sleep study).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that you have been taking these for years and it is 
the only thing that helps. These have always been approved so you are not sure why they are being denied now. 
The Plan denied your request. The Plan says under the Medicare rules this request for lumbar facet injections 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 the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had bilateral lumbar facet on October 27, 2022 with good pain relief of 50%. The 
LCD criteria to repeat the block is 80% pain relief. This was not achieved. Therefore, the request is deemed no 
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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar facet joint injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you are having surgery. You say that the 
surgeon has requested no weight bearing. You also say that you need this. The Plan denied your request. The 
Plan says the requested device is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these are not covered items. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0675 and E0673).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular repair of infrarenal aorta and/or iliac 
artery(ies) by deployment of an aorto-uniiliac endograft. 
 
You asked the Plan to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) by 
deployment of an aorto-uniiliac endograft. You say that the requested procedure is medically necessary and 
there are no alternatives for this patient. The Plan denied your request. The Plan says endovascular repair of 
infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uniiliac endograft is not medically necessary. 
The patient does not have an aneurysm or any complications requiring this procedure. 
 
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 endovascular repair of infrarenal aorta 
and/or iliac artery(ies) by deployment of an aorto-uniiliac endograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of an aneurysm or dilatation of the aorta or other abnormality of the aorta 
noted on either the computed tomography (CT) angiogram or the catheter-based angiogram that would 
necessitate endograft repair. Both studies identify multilevel calcific arterial occlusive disease. There is no 
documentation in the medical records provided of a plan for treatment including any mention in the medical 
record that an aorto uni-iliac endograft is being considered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of 
an aorto-uniiliac endograft have not been met. Therefore, we decided that the Plan does not have to pre-
approve endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uniiliac 
endograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says an 
ankle brachial indices has not been done. 
 
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 requested services. Our physician 
reviewer found that you have complaints of leg and foot pain in the setting of noninvasive studies suggesting 
normal arterial flows at the level of the femoral and popliteal artery with elevated velocities in the tibial arteries 
without suggestion of occlusion. As you have a history of neuropathy involving the lower extremities, and as 
tibial artery intervention has the potential to do more harm than good, a request for more objective, 
noninvasive, is appropriate. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not approved for the enrollee's clinical scenario. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has a diagnosis of stage 3 squamous cell lung cancer who had progression of 
disease while receiving durvalumab. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. Therefore, the requested service cannot be 
recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Yervoy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that you need this CGM. The Plan denied your 
request. The Plan says a Freestyle Libre 3 is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).