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

 
We decided that the Plan does not have to pre-approve external ambulatory infusion pump, insulin (CPT code 
E0784) and supply allowance for adjunctive CGM, includes all supplies and accessories, 1 month supply = 1 
unit of service (CPT code A4238). 
 
You asked the Plan to pre-approve the items. You say that the fact that the enrollee's C-peptide show that the 
enrollee's body still produces insulin does not tell the full story. The Plan denied your request. The Plan says 
the request for an insulin pump is not medically necessary because the C-peptide testing requirement has not 
been 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 the items. Our physician reviewer 
found the enrollee does not meet coverage criteria for a pump 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve external ambulatory infusion pump, insulin (CPT code E0784) and supply allowance for 
adjunctive CGM, includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code A4238).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the requested SNF care does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee qualifies for SNF coverage. 
You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You have 
a new fracture, for which strength training, transfer training and durable medical equipment assessment is 
medically necessary and reasonable. Daily skilled services are required to establish a maintenance program 
and/or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, you do not qualify for SNF coverage. You do 
not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and 
intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral finger prostheses. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a current non-functioning 
prostheses. The submitted clinical information supports the need for replacement prostheses. The services are 
reasonable and medically necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve bilateral finger prostheses.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod 5 G6 intro kit. 
 
You asked the Plan to pre-approve the supplies. You say that the system is necessary. The Plan denied your 
request. The Plan says Omnipod disposable insulin pump system supplies are not a covered benefit under the 
enrollee's Medicare Part B. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. The rules say disposable drug 
delivery systems, including elastomeric infusion pumps are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Therefore, we decided that the Plan does not have to pre-
approve Omnipod 5 G6 intro kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio Stimulator provided on June 20, 2022. 
 
You asked the Plan to pay for the Cala Trio Stimulator. You say that the Cala Trio Stimulator provided on June 
20, 2022, was medically necessary. The Plan denied your request. The Plan says the Cala Trio Stimulator 
provided on June 20, 2022, was 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 pay for the Cala Trio Stimulator. Our reviewer says 
that the Cala Trio Stimulator provided on June 20, 2022, was not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the Cala Trio Stimulator provided 
on June 20, 2022, at issue in this case meets all Medicare criteria. Although there is some support for use of 
devices such as the one in this case, provided records do not document trial and failure of the primidone 
prescribed in this case which is first line therapy for essential tremor. Also, as stated in the NCD, the use of 
electric nerve stimulation in the treatment of motor function disorders is a recent innovation, and the medical 
effectiveness of such therapy has not been verified by scientifically controlled studies. No reimbursement may 
be made for the stimulator where its use is to treat motor function disorders. 
 
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 Cala Trio Stimulator have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cala Trio Stimulator provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on June 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services rendered by an OON 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit services provided on June 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic (PGx) testing provided on April 12, 2022. 
 You asked the Plan to pay for PGx testing. You say that this test was medically necessary and is supported in 
the medical record. The Plan denied your request. The Plan says the criteria for coverage of pharmacogenomic 
testing are not met in this case, and therefore this test is not considered 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 pay for PGx testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has diagnoses of mixed hyperlipidemia, adjustment disorder, and hypertension. 
There is no documentation from the enrollee's treating physician describing the purpose for the 
pharmacogenomic testing and how it would affect the enrollee's treatment plan. This review has determined 
that the records do not support that the criteria for PGx testing are met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PGx testing have not been met. Therefore, we decided that the Plan does not 
have to pay for pharmacogenomic (PGx) testing provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI), without imaging 
guidance (62322). 
 
You asked the Plan to pre-approve ESI without imaging guidance. You say that you have been receiving caudal 
injections under ultrasound guidance since December 2019. You say that you pain relief varies, but for the 
most part it is greater than 50%. You say that it lasts 3 to 4 months. You also say that your last injection was 4 
months ago, and the pain is starting to return. The Plan denied your request. The Plan says the injection without 
imaging guidance is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs must be performed under computed tomography 
(CT) or fluoroscopy image guidance with contrast. 
 
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 ESI without imaging guidance. Our 
reviewer says that an ESI without imaging guidance is not medically necessary. Our physician reviewer found 
the coverage guidelines require the use of imaging when performing an ESI. Therefore, the reviewer found that 
the requested ESI without imaging guidance 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 ESI without imaging guidance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an epidural steroid injection (ESI), without imaging guidance (62322).
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 enrollee has completed their current 
stay, is stable for transfer, and clearly exceeds the criteria for an appropriate LTACH admission. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to LTACH. 
 
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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. Transfer to the LTACH is not medically necessary at this time as it would not be clinically 
advantageous and completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion 
(CPT code 27279). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found there is no documented sacroiliac (SI) joint instability, fracture, or lesion. MIS SI joint fusion is 
experimental for degenerative 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion (CPT code 27279).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 22, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the ET3 
program is a Medicare Fee for Service program that does not apply to members who are enrolled in a Medicare 
Advantage 
plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
In this case, the Plan is not required to pay for treatment in place, as this was billed under the ET3 program. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 22, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDX testing provided on June 18, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing is covered for the 
indications established in the applicable NCD. 
 
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 pay for the testing. Our reviewer says that the 
requested testing was medically reasonable and necessary. Our physician reviewer found that FoundationOne 
CDx is the first FDA-approved tissue-based broad companion diagnostic (CDx) that is clinically and 
analytically validated for all solid tumors. In this case, the enrollee has advanced pancreatic cancer. The 
requested FoundationOne CDX testing is medically reasonable and necessary according to the NCD coverage 
criteria. 
 
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 testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDX testing provided on June 18, 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 pay for the inpatient hospital services provided on August 3, 2020, at 
the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of code A41.9 is not supported by the records provided. Our physician reviewer 
found that the enrollee was treated with antibiotics and surgery was consulted, which recommended non-
surgical 
management. Interventional radiology was then consulted, and a drain was placed. In the emergency room, 
vital signs noted a heart rate of 104, a respiratory rate of 17, a blood pressure of 154/98, a SpO2 of 99%, and a 
temperature of 99.4. The physical exam indicated that the enrollee was not ill-appearing and not in acute 
distress. There was no clinical or laboratory evidence of sepsis. The use of diagnosis code A41.9 was not 
supported by the records provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on August 3, 2020, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of anesthetic or steroid into joint between 
lower spine and hip bone using imaging guidance (CPT code 27096). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that the enrollee only had six (6) days of relief with previous sacroiliac (SI) 
injection 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of anesthetic or steroid into joint between lower spine and hip bone using 
imaging guidance (CPT code 27096).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.