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

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Receiver. 
 
You asked the Plan to pre-approve the Dexcom G6 Receiver. 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 the Dexcom G6 Receiver. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
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, 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 the Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre 2 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants (D6010).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance service, basic life support, emergency transport provided 
on May 8, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that the 
medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan 
says that the ambulance transport was not a medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport. Our reviewer says that the ambulance transport service was medically necessary. Our 
physician reviewer found the enrollee's presenting symptoms did meet prudent layperson criteria for emergency 
care. The enrollee was being transferred from one hospital facility to a second hospital facility for higher level 
of care. Transportation by ambulance 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 ambulance service, basic life support, emergency transport have not been 
met. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, emergency 
transport provided on May 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at high risk of returning to 
a short- term acute care hospital if they go to a skilled nursing facility. You say that the enrollee would have a 
maximized benefit at an LTACH. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 98942) 
provided from May 2, 2022, through September 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic manipulative treatments provided 
in this case are considered maintenance therapy as billed. Maintenance therapy is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 
98942) provided from May 2, 2022, through September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral axial decompression treatments, per session 
(S9090). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pre-approve vertebral axial decompression treatments, per session (S9090).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nubeqa tablet. 
 
You asked the Plan to pre-approve Nubeqa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B because it is an oral anti-cancer drug that does not have the same active ingredients as a non-
self-administrable anti-cancer chemotherapeutic drug or biological. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Nubeqa tablet.  
 
Benefits for Nubeqa 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve continuous glucose monitor (CGM) supplies. The Plan denied your request. 
The Plan says the enrollee does not require insulin three or more times daily. 
 
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 
continuous glucose monitor (CGM) supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the lumbar spine. 
 
You asked the Plan to pre-approve the CT of the lumbar spine. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee must have a plain x-ray first after you have 
had spine surgery. 
 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT of the lumbar spine. Our 
reviewer says that the CT scan of the lumbar spine is not medically necessary. Our physician reviewer found 
the enrollee has no neurological deficit and the medical necessity of a non-enhanced CT of the lumbar spine 
has not been established in this case. The yield of a non-enhanced CT of the lumbar spine is low especially in a 
post operative fusion case. While the tremors may produce motion artifacts, the highest yield imaging study 
after the plain films would be a magnetic resonance imaging (MRI) if the medical necessity were to be 
established. 
 
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 of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
Tooth #8 and 9. 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services approved 
to complete your treatment plan. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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. This benefit includes the 
requested pontic - porcelain fused to high noble metal and retainer crown  porcelain fused to high noble metal 
but is limited up to four units of fixed dentures per year, covered one per tooth per life.  We looked at the file, the Plans rules, and Medicares rules. You previously have been pre-approved for 
covered retainer crown - porcelain fused to high noble metal (D6750) Tooth 6, 7, 10, 11 with authorization date 
from February 27, 2023, to March 28, 2023. Although D6750 and D6240 are two different services, they fall 
within the same category in your Evidence of Coverage and are subject to the same frequency limitations. 
Therefore, these benefits were exhausted. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain fused to high noble metal (D6240) Tooth #8 and 9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray examination of the swallowing function (74230) 
and x-ray of the upper gastrointestinal tract (74240) provided on October 11, 2022. 
 
  You asked the Plan to pay for the x-rays. You say that these services were performed at the request of the 
primary care physician at the facility. You also say that the treating company is contracted with the facility, and 
these services should be paid. The Plan denied your request. The Plan says these services are not covered 
benefits under the enrollees plan and are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures involving fluoroscopy and procedures 
involving the use of contrast media are not covered under the portable x-ray provision. 
 
We looked at the file and Medicare rules. The services provided were for a barium swallow study in the 
portable mobile radiology setting. This imaging requires both the use of fluoroscopy and contrast. Based on 
this information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we 
decided that the Plan does not have to pay for the x-ray examination of the swallowing function (74230) and x-
ray of the upper gastrointestinal tract (74240) provided on October 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve refill of drugs for an intrathecal pain pump to be done in 
the home setting. 
 
You asked the Plan to pre-approve the at-home pain pump refill services. You say that this is medically 
necessary as a nurse can be sent to the enrollee's home to refill the pump before the medication runs out, and 
the enrollee goes into withdrawal. The Plan denied your request. The Plan says there are in-network providers 
who are able to refill the pain pump. 
 
The Plan must follow Medicare rules. Medicare rules say that drugs may only be covered when they are 
provided incident to physician services. The services of auxiliary staff may also be covered by the incident-to 
provision, but only if the physician is personally present for supervision.  
We looked at the file and Medicare rules. It is noted that the request is for nurses, not a physician, to go to the 
enrollee's home to administer the drug into the pump. Neither a nurse's services nor drugs can be covered by 
Medicare Part B if there is no physician present. As such, the requested type of at-home refill for an implanted 
pump is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve refill of 
drugs for an intrathecal pain pump to be done in the home setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that you want to appeal this denial. 
The Plan denied your request. The Plan says a power seat elevation system does not have a medical purpose. 
 
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 power seat elevation system (E2300).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you need to have an MRI to find 
out what is going on with you as you have tried physical therapy and it has not worked. The Plan denied your 
request. The Plan says an MRI of the lumbar spine 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 MRI of the lumbar spine. Our reviewer 
says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that there is a 
report of an MRI of the lumbar spine in the records dated January 13, 2023, which was reviewed by the 
requesting physician. The need for a repeat exam is not supported in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the lumbar spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 83550. The Plan denied your request. The Plan says payment for 
code 83550 is bundled into payment for code 84466. 
 
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 83550 is a column II code to column I code 84466 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 83550 
billed for date of service July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) and a pontic (D6240). 
 
You asked the Plan to pre-approve a retainer crown (D6750) and a pontic (D6240). You say that you are 
missing your front tooth and have trouble chewing solid food. The Plan denied your request. The Plan says  
this is not a covered expense under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. A retainer crown and pontic together make a bridge, which is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6750) 
and a pontic (D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27530 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 27530. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 27530 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 27530 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27530 billed for date of service May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one unit of procedure code 81455 billed for date of service 
April 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records prove medical necessity. 
The Plan denied your request. The Plan says a panel of tests should be billed under a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel was not billed with a single code as required. Specifically, code 81455 was billed 
twice for one panel. Providers must not unbundle services, but bill with the most comprehensive code and 
number of units accurately reflecting the services provided. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
one unit of procedure code 81455 billed for date of service April 6, 2022.