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

 
We decided that the Plan does not have to pre-approve an extracranial bilateral study (93380). 
 
You asked the Plan to pre-approve an extracranial bilateral study. You say that this imaging 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 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 extracranial bilateral study. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in the absence of physical findings and or history of established 
atherosclerosis, peripheral vascular disease (PVD), cerebrovascular accident (CVA), transient ischaemic attack 
(TIA), or carotid surgeries/stents, external duplex ultrasound studies do not benefit the 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 extracranial bilateral study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an extracranial bilateral study (93380).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total revision of left hip arthroplasty. 
 
You asked the Plan to pre-approve total revision of left hip arthroplasty. You say that you disagree with the 
Plan's 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 total revision of left hip arthroplasty is only covered 
when pain or other symptoms occur as a result of failure of the prior surgery. 
 
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 total revision of left hip arthroplasty. 
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 left hip pain despite a previous left total hip 
arthroplasty. The x-rays do not show severe bone loss and loosening and do not support the indication for hip 
revision. More imaging studies are needed to show failure of previous surgery. 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 total revision of left hip arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve total revision of left hip arthroplasty.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303) 
 
You asked the Plan to pre-approve a hospital bed. You say that the medical records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for the requested hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds.  
We looked at the file and Medicare rules. The records show that the enrollee weighs 225 pounds Based on this 
information, we decided that Medicare rules for coverage of a hospital bed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed with weight capacity 
greater than 350 pounds, but less than or equal to 600 pounds (E0303)
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the home health services. You say that the home health services are 
medically necessary. The Plan denied your request. The Plan says the requested provider is an OON provider, 
and the enrollee has been approved for the home health services with an in-network 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 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 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. 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 follows Medicare rules. Medicare rules say that a transthoracic echocardiography (TTE) is covered 
under certain circumstances. 
 
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 TTE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found documentation would not point to a change in status that would support the medical necessity of a repeat TTE at this time. Clinical guidelines do not 
support repeating a TTE following a previous TTE, with no intervening change in clinical status or new signs, 
symptoms or physical findings. In summary, there is no supportive evidence for the medical necessity of repeat 
TTE in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11721 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative calcium 
scoring (75571). 
 
You asked the Plan to pre-approve a CT with quantitative calcium scoring. You say that you have a family 
history of heart disease, and this service is necessary to see if you have a problem which will require 
medication. The Plan denied your request. The Plan says the medical records do not indicate that you have any 
personal symptoms, only a family history. That means that this test is requested for screening purposes; 
however, this test is not covered as a screening. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a CT with quantitative calcium scoring, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography (CT) with quantitative calcium scoring (75571).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted case management to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve targeted case management to be provided by an out-of-network provider. 
You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve targeted 
case management to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73220 billed for date of service October 25, 2022. 
 
You asked the Plan to pay for code 73220. You say that this service was rendered in an appropriate place of 
service. The Plan denied your request. The Plan says you billed an incorrect Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the correct Place of Service 
(POS) code on the claims they submit. POS code 11 represents services taking place in an office setting. POS 
code 21 should be used for services rendered in an inpatient hospital setting.  You billed the service in dispute 
with a POS code of 11. However, records indicate that the patient was in an inpatient setting on this date of 
service, so POS code 21 should have been used. Therefore, we decided that the Plan does not have to pay for 
code 73220 billed for date of service October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pedicle soft tissue graft procedure (D4270). 
 
You asked the Plan to pre-approve dental services. You say that you have a serious infection, so it is important 
to have this service approved. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Pedicle soft tissue graft 
procedure (D4270) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4270 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve pedicle soft 
tissue graft procedure (D4270).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 72-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that the enrollee needs 
transportation to dialysis appointments. The Plan denied your request. The Plan says the requested number of 
trips will exceed the enrollees routine transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
72-trip limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says as of March 25, 2023, the enrollee has used 
all inpatient psychiatric hospital days that are covered under the Plan. There is a 190-day lifetime limit for 
inpatient psychiatric hospital days. 
 
The Plan contract covers inpatient services in a psychiatric hospital. The Plan contract says there is a 190day 
lifetime limit for inpatient services in a psychiatric hospital. 
 We looked at the file and the Plans rules. The file shows that the enrollee has exhausted the Plans benefit 
limit for inpatient services in a psychiatric hospital. Therefore, we decided that the Plan does not have to pre-
approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is part of the surgical 
recovery process. You say that you need this device to fully recover. The Plan denied your request. The Plan 
says the requested device is statutorily excluded from coverage under the Medicare Durable Medical 
Equipment benefit and is also not covered under your Evidence of Coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes J2353, 96372, and G0463 billed for March 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the information submitted is insufficient for processing per ambulatory classifiation. 
 
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 states that the services are insufficient for processing, however; there is 
no further explanation as to why the services are denied. The Plan has not provided any documentation or 
referenced any binding Medicare rules to support that the services are not payable as billed. Therefore, we 
decided that the Plan has to pay for procedure codes J2353, 96372, and G0463 billed for March 28, 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 Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor kit. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is checking her blood sugars four 
times a day and has uncontrolled A1c levels. The Plan denied your request. The Plan says the criteria are 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 treat with 
insulin three or more times per day or use an insulin pump. 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 Freestyle Libre 2 continuous glucose monitor (CGM) sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you need this benefit. The Plan denied your request. 
The Plan says you do not meet the criteria for coverage of this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not meet all of the criteria 
for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefit for 
the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found bone marrow aspirate is 
experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation mileage for a round trip. 
 
You asked the Plan to provide additional routine mileage. You say that you need to see this specialist twice per 
year and have no other way to get to these appointments. The Plan denied your request. The Plan says the 
requested destination is a greater driving distance than what is covered by your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation trips within 50 miles of driving distance.  
 We looked at your request, the records in the case file, and the rules. The requested destination is more than 50 
miles away. Based on this information, we decided that the Plans rules for coverage of routine transportation 
have not been met. Therefore, we decided that the Plan does not have to provide additional routine 
transportation mileage for a round trip.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart pulse generator. 
 
You asked the Plan to pre-approve an Optimizer Smart pulse generator. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Optimizer Smart pulse generator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac 
contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system is not considered to be medically necessary in 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 Optimizer Smart pulse generator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an Optimizer Smart pulse generator.