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

 
We decided that the Plan does not have to pay for the services provided on October 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.   
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on October 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, SI joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device, (LinQ) (CPT code 27279). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says until the medical studies in the current pipeline have reported results which 
definitively show this procedure and device to be a safe and effective treatment for SI joint pain it is not 
reasonable or necessary for Medicare to provide coverage. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
diagnosis of sacroiliitis. There is no clear history of SI joint pain onset or failure of conservative treatment directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine are evident. 
Regardless, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with image 
guidance, includes obtaining bone graft when performed, and placement of transfixing device, (LinQ) (CPT 
27279), 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with 
image guidance, includes obtaining bone graft when performed, and placement of transfixing device, (LinQ) 
(CPT code 27279).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections of Orthovisc are only covered when 
six months have passed since the prior series of injections. 
 
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 Orthovisc. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has pain related to osteoarthritis of the right knee who improved with 
Orthovisc injections to the knee in February 2022. Based on the medical records provided repeat Orthovisc 
injections less than six months after the completion of the prior series of injections does not meet Medicare 
criteria for coverage. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with special features. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says a total electric bed is not a benefit of the Medicare program or the health 
plan. 
 
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 a total electric hospital bed have not been met. A total electric 
hospital bed is not covered. Total electric beds will be denied as not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pre-approve a total electric hospital bed with special features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that the requested replacement 
power wheelchair is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair 
received by the enrollee in 2018. Therefore, the requested replacement is for an item that has not outlasted its 
reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a 
replacement power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that you had a fainting spell back in February 
and you collapsed. You also say that you need to have this device on your body so that you do not have another 
episode. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 Dexcom G6 CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector for a power wheelchair. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the enrollee 
does not have a medical need to control the power options from a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
 
 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 item. Our physician 
reviewer found that the enrollee has multiple comorbidities and a past medical history of stroke with right sided 
weakness. Authorization for group 3 power wheelchair with power tilt and electronic connection to the joystick 
is being requested. The only power function being requested is power tilt due to previous wound issues. The 
clinical records do not show that the enrollee would be unable to utilize this switch for power tilt function. 
 
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 item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electronic connector for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the submitted clinical information does not show that the requested 
services are medically necessary and one of the following situations applies: It is unreasonable to expect you to 
return to the service area for treatment, delay of treatment would likely result in a significant decline in your 
health or medically necessary services are not available in the service area. 
 
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 
diabetic shoes to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support the 
services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that specimen validity testing 
is not covered separately. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (83789) provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a mastectomy sleeve (L8010) is denied as noncovered 
 
We looked at the file and Medicare rules. The item at issue is a mastectomy sleeve. Therefore, we decided that 
the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency, non-ambulance transportation provided 
from March 26, 2021, to August 12, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the provider on March 26, 2021 advised 
they did not accept Medicare or your plan. You also say that the enrollee did not have a choice as to what type 
of transportation was used on August 12, 2021. The Plan denied your request. The Plan says routine 
transportation services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
 
 
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergency, non-ambulance transportation provided from March 
26, 2021, to August 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 6, 2020, to November 4, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
denied for no plan of care. 
 
The Plan must follow Medicare rules. The rules say that all home health care provided must be in accordance 
with the plan of care. 
 
We looked at the claim submitted, the file and the Medicare rules. The records provided did not include a plan 
of care as required. Based on this information, we decided that Medicare rules for completing the claim for the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from October 6, 2020, to November 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external counterpulsation (ECP) therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ECP therapy is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the ECP device has been approved by 
the Food and Drug Administration (FDA) for treating a number of cardiac conditions; however, there has not 
been sufficient clinical evidence to support its use for your indication of post-acute COVID-19 syndrome. The 
services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve external counterpulsation (ECP) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic neck pain with 
occasional numbness and tingling sensations in the arms. You had a cervical ESI on March 22, 2022 that 
provided 60 percent pain relief for two weeks and on April 19, 2022 that provided 50 percent pain relief for an 
unknown duration. There is no documentation that you had sustained pain relief for three months after the two 
previous ESIs. The criteria for coverage are not met and the repeat ESI is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right and left 
hip; without contrast material (73721). 
 
You asked the Plan to pre-approve this service. You say that an MRI of the right and left hip is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the original notes received did 
not indicate that you completed six weeks of provider directed treatment. Supported treatments include (but are 
not limited to) drugs for swelling or pain, an in-office workout (physical therapy), and/or oral or injected 
steroids. This must have been completed in the past three months without improved symptoms. In this case, 
there is no specific clinical rationale for the requested MRI study. The review has determined that an MRI 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 this service have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the 
right and left hip; without contrast material (73721).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81301, 81311) provided October 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met.  
 
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301, 81311) provided October 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cialis. 
 
You asked the Plan to pre-approve Cialis. You say that Cialis is medically necessary. You say that the enrollee 
has other diseases that do not make him a good candidate for alternative medications. The Plan denied your 
request. The Plan says this Medicare Advantage Plan does not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cialis.  
 
Benefits for Cialis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic (CT) colonography, diagnostic, 
including image post processing (74261) provided on February 4, 2022. 
 
You asked the Plan to pay for the CT. You say that the service should be covered. The Plan denied your 
request. The Plan says the service 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 CT. Our reviewer says that the requested 
CT are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation does not indicate a specific clinical indication for the requested computed tomographic 
(CT) colonography, diagnostic, including image post processing (74261). The review has determined that the 
documentation did not support that the service was 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 CT have not been met. Therefore, we decided that the Plan does not have to 
pay for the computed tomographic (CT) colonography, diagnostic, including image post processing (74261) 
provided on February 4, 2022.