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

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says that the enrollee has 
not met the coverage criteria. 
 
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 enrollee has not met the coverage criteria. However, the 
Plan has not provided medical records from the contracted provided showing that the coverage criteria for the 
requested CGM have not been met. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).  
 
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 Lutetium therapy from an out-of-network (OON) 
provider. 
 
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 available from network providers. 
 
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 
Lutetium therapy from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the requested benefits are a medical necessity 
for you. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet all the 
required criteria. Therefore, we decided that the Plan does not have to pre-approve SSBCI benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia.  
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The 
documentation does not support that the enrollee has tried and failed an oral and intravenous bisphosphonate 
(alendronate and zoledronic acid). The documentation does not support that an oral and intravenous 
bisphosphonate (alendronate and zoledronic acid) would likely  be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 21, 2022, through 
September 26, 2022, billed with procedure codes 99232 and 99233. 
 You asked the Plan to pay for the medical services.. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says diagnosis code F05 has a code first note and is 
not acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans, physicians, hospitals, and other 
health care providers must comply with the Official International Classification of Disease, 10th Edition, 
Clinical Modification (ICD-10-CM) Coding Guidelines.  
 
We looked at the file and Medicare rules. Specifically, this claim was billed with primary diagnosis code F05. 
Diagnosis code F05 has a code first note indicating that it is not an appropriate primary diagnosis. Based on 
this information, we decided that Medicare rules for coverage of the medical services. have not been met. 
Therefore, we decided that the Plan does not have to pay for medical services provided on September 21, 2022, 
through September 26, 2022, billed with procedure codes 99232 and 99233.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LightEase-Leg elevational pillow. 
 
You asked the Plan to pre-approve these services. You say that you need the pillow to assist in recovery after 
foot surgery. The Plan denied your request. The Plan says the item is not covered. 
 
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 LightEase-Leg elevational pillow.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CPAP device. You say that the Plan's approved device is not in stock. 
The Plan denied your request. The Plan says the device should be acquired through a contracted 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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device to be provided by an out-of-network (OON) provider.
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 CGM. You say that it is medically necessary for the enrollee to be on a 
CGM due to their medical conditions. The Plan denied your request. The Plan says the Medicare criteria was 
not met. 
  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 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 sacroiliac-joint fusion procedures (27279, 27280). 
 
You asked the Plan to pre-approve sacroiliac-joint fusion. 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 sacroiliac-joint fusion. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documented sacroiliac-joint instability, fracture, or lesion. Sacroiliac-
joint fusion is experimental for 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 sacroiliac-joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac-joint fusion procedures (27279, 27280).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
27, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that these services are supported as billed. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM. You say that the enrollee needs this device to 
monitor blood glucose levels on a continuous basis. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for coverage of a CGM. 
 
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 a Freestyle Libre 2 CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 2, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek guide strips. 
 
You asked the Plan to pre-approve Accu-Chek guide strips. You say that you disagree with the Plans denial. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-Chek guide strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek guide 
strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing care and home 
health services. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a medical history of diabetes mellitus type II and stroke with hemiplegia and aphasia. The enrollee 
has been receiving home health nursing care since June 30, 2019. Home health documentation dated March 14, 
2023, indicated that the enrollee is taking oral medications, except for subcutaneous insulin. The enrollee and 
their family have been fully trained to provide care in the absence of nursing coverage. The enrollee is 
receiving personal care assistance. The enrollee was last hospitalized from January 19, 2023, to January 22, 
2023, for the removal of an oral neoplasm. The enrollee was noted to have expressive aphasia but be 
cognitively aware. The enrollee requires assistance and supervision when ambulating. 
 
The enrollee is noted to have stable vital signs and their medical conditions are stable. The enrollee does not 
require wound care, catheterization, G-tube feeding, or administration of IV or complex medications. The 
enrollee requires subcutaneous insulin for management of his diabetes mellitus and the family and enrollee 
have been trained to administer it as well as assess their blood sugar. The enrollee does not require skilled 
nursing care twice daily in the home. The enrollee also receives personal care assistance for mobility and there 
is no need for other home health services, including physical or occupational therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health skilled nursing care and home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Durolane. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have a history of left knee pain due to osteoarthritis. You have been treated with medical 
therapy with Celebrex and have received a corticosteroid injection.  
 
Intra-articular injections with hyaluronic acid (Synvisc) are recommended as a possible option for severe 
osteoarthritis for patients who have not responded adequately to recommended conservative treatments 
(exercise, NSAIDs, and/or Acetaminophen) to potentially delay total knee replacement.  However, in recent 
quality studies, the magnitude of improvement appears modest at best. While osteoarthritis of the knee is a 
recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patellae, osteochondritis dissecans, or patellofemoral syndrome (patellar knee pain).  
Hyaluronic acids are naturally occurring substances in the body's connective tissues that cushion and lubricate 
the joints.  Intra-articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee; there 
are significant improvements in pain and functional outcomes with few adverse events. 
 
The clinical information does not state that you have tried and/or failed any course of conservative treatments. 
The documentation does not support that Durolane is medically reasonable or necessary. Therefore, you do not 
meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations of the sacroiliac (SI) joint 
(codes 64635 and 64636) 
 
You asked the Plan to pre-approve the radiofrequency ablations. You say that the enrollee's SIJ radiofrequency 
ablation has been proven effective, with pain relief lasting eight months. You also say that you recommend that 
a repeat procedure be covered, and the procedure should be considered a reasonable and effective part of the 
enrollee's pain management plan, with the possibility of repeating after six to twelve months. The Plan denied 
your request. The Plan says the denial of radiofrequency ablation to the SI joint was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation is not considered reasonable and 
necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablations of the sacroiliac (SI) joint (codes 64635 and 64636)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that this equipment is not medically necessary. Our physician reviewer found there is no 
documentation that a standard portable oxygen system is not meeting the patient's needs. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.