Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87634, 87640, 87798, U0003 and U0005) provided on September 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical records. The Plan denied your request. The Plan says that medical records are required to 
support this claim. 
 
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. Specifically, medical records for these services have been provided since the 
Plan's initial denial. The Plan has provided no other reason for denial of these services. Therefore, we decided 
that the Plan has to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 
87640, 87798, U0003 and U0005) provided on September 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and an appliance. You say that you are requesting 
reconsideration based on the clinical records submitted for review. The Plan denied your request. The Plan says 
although the provider documented the enrollee failed a conservative treatment trial after her vascular 
procedure, no objective documentation, or subsequent reassessments of the enrollee's response to conservative 
therapy has been submitted. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
 
 
 
 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 pneumatic compressor and an 
appliance. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
local coverage determination enumerates the conditions and limitations under which coverage is available for 
the requested service. In this case, the record indicates that the enrollee has venous insufficiency and underwent 
a surgical procedure.  The record provided indicates that the enrollee had improvement following the 
procedure. The records provided do not indicate that the enrollee has failed conservative therapy following the 
surgical procedure. The elements of the coverage criteria are not satisfied. The requested service is not 
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 a pneumatic compressor and an appliance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model without 
calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block. 
 
You asked the Plan to pre-approve peripheral nerve block. You say that the enrollee needs this monthly. The 
Plan denied your request. The Plan says the enrollee has received 3 nerve blocks within the past 4 months. 
 
The Plan follows Medicare rules. Medicare rules state that more than 3 peripheral nerve blocks per anatomic 
site in a six month period will be denied. 
 
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 peripheral nerve block. Our reviewer 
says that the enrollee does not meet criteria for this injection. Our physician reviewer found the enrollee has 
already had 3 injections in the preceding 3 months. Therefore, continued injections would not be supported 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 peripheral nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a peripheral nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
December 29, 2021, to December 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says an inpatient level of care was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that following transfer from the emergency department, the enrollee was found to be 
stable and in normal rhythm. As a result, the enrollee was discharged from the hospital with outpatient follow-
up planned. The admission for hospital admission was entered at the same time as the order for hospital 
discharge. As such, the requested inpatient hospitalization would not be considered medically necessary in this 
enrollees clinical management based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 29, 2021, to  
December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar L3 peri-screw hardware injection. 
 
You asked the Plan to pre-approve a lumbar L3 peri-screw hardware injection. You say that a lumbar L3 
peri-screw hardware injection is medically necessary. The Plan denied your request. The Plan says a lumbar L3 
peri-screw hardware 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 a lumbar L3 peri-screw hardware 
injection. Our reviewer says that the requested lumbar L3 peri-screw hardware injection is not considered 
medically reasonable and necessary. Our physician reviewer found that mobility of pedicle screws is not  
addressed by pain blocks. There is no surgical consultation submitted for review. 
 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 lumbar L3 peri-screw hardware injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar L3 peri-screw hardware injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on June 14, 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 (PCD) (E0675) and appliance (E0673) provided on June 14, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services you requested do not meet the 
requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that a corrected claim was faxed. The Plan denied 
your request. The Plan says there are no clinical records to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. We find that the billed code is not supported. Specifically, medical 
records were not provided to show the testing service was provided, or the reasoning for the testing. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93306 billed for date of service May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial. The Plan denied your request. The Plan says you must use network providers to get your medical care 
and services. There are in network providers within 25 miles of your home address that can provide the 
services. 
 
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 
a power wheelchair and accessories 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 the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an implanted loop recorder (ILR) is used when 
syncope is thought to be cardiac-related, but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR. 
 
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 implantable loop recorder. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found there is no 
documented syncope for this enrollee. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Licensed Surgical 
Assistant (LSA) on April 11, 2022. 
 
You asked the Plan to pay for the LSA services. You say that the primary surgeon who performed the surgery 
is an in-network provider, so this claim should be paid. The Plan denied your request. The Plan says Medicare 
does not make payment for surgical assistant services provided by a LSA. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Licensed Surgical Assistant (LSA) on April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (ESI) (64483, 64484). 
 
You asked the Plan to pre-approve the ESI injections. You say that the medical records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the repeat ESI's at the same 
anatomical sites using the same transforaminal approach and same medications are not reasonable or necessary 
at this time. 
 
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 ESI injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested repeat epidural steroid injection (with the same approach, level and 
medication as the January 18, 2023 injection) is not medically reasonable and necessary as the documentation does not reveal at least 50% of sustained improvement in pain relief and/or improvement in function measured 
from baseline using same scale for at least three months. Local Coverage Determination (LCD) Epidural 
Steroid Injections for Pain Management L33906 criteria have not been met. 
 
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 ESI injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the epidural steroid injections (ESI) (64483, 64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
melanocytoma of the meninges. The Food and Drug Administration (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 services are not reasonable or medically 
necessary 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Mis 2 Reader. 
 
You asked the Plan to pre-approve a Freestyle Libre Mis 2 Reader. 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. 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 a 
Freestyle Libre Mis 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Mis 2 Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 26, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other 
than spinal applications (E0747). 
 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that the provider ordered this stimulator 
to help promote bone growth and fracture consolidation. The Plan denied your request. The Plan says the 
request is not medically necessary because the enrollee's serial radiographs demonstrate callus formation and 
healing of the fractures. 
 
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 osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for unspecified fracture of shaft of 
unspecified fibula. Detailed documentation is not evident regarding a non-union of the fracture. The last 
reported x-rays from December 5, 2022, were noted to corroborate stable periosteal callus formation along the 
anterior margin of the tibia. The previous x-rays were not provided. Serial x-rays are needed to corroborate the 
lack of progression/healing of the noted tibial and fibular fractures. Additionally, current peer-reviewed 
literature indicates that further large, randomized, controlled trials are required to support the use of electrical 
bone growth stimulators in the treatment of long-bone non-unions. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested non-spinal electrical osteogenesis stimulator, in this case, is not medically reasonable or 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 an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other than spinal 
applications (E0747).