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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you do not want to keep pricking your finger. The 
Plan denied your request. The Plan says the medical criteria for a CGM have 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 use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37229. We decided that the Plan does not have to pay for 37253.  
 
You asked the Plan to pay for procedure codes 37229 and 37253 rendered on March 17, 2022.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
 
 We decided that the Plan has to pay for 37229.  
 
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, the CPT Code Manual definition of 
CPT 37229 is "Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 
vessel; with atherectomy, includes angioplasty within the same vessel, when performed." 
 
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 for CPT 37229. Our reviewer says that there is 
documentation that atherectomy with percutaneous transluminal angioplasty of the peroneal artery was 
performed including the atherectomy and the use of a 2.5mm balloon. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
37229.  
 
We also decided that the Plan does not have to pay for 37253. 
 
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, the CPT Code Manual definition of 
CPT 37253 is "Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 
intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List 
separately in addition to code for primary procedure)." 
 
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 for CPT 37253. Our reviewer says that there is 
insufficient detail with respect to intravascular ultrasound (IVUS) findings to justify coverage of this code, in 
addition to what has already been approved and covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37253 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37253. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on June 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service June 14, 2022.  Specifically, the Plans contract states that one limited oral evaluation is covered per plan year. You previously 
received this service on June 14, 2022, which was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation-problem focused (D0140) provided on June 23, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the injection, Bortezomib (Velcade), 0.1 mg. (J9041) provided on 
October 1, 2021. 
 
You asked the Plan to pay for the injection, Bortezomib (Velcade), 0.1 mg. You say that the injection, 
Bortezomib (Velcade), 0.1 mg. was medically necessary. The Plan denied your request. The Plan says that the 
injection, Bortezomib (Velcade), 0.1 mg. is experimental/investigational.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection, Bortezomib (Velcade), 0.1 mg. 
Our reviewer says that the injection, Bortezomib (Velcade), 0.1 mg. is considered medically necessary. Our 
physician reviewer found maintenance therapy until toxicity or progression is a standard of care endorsed by 
the National Comprehensive Cancer Network Guidelines. The enrollee has maintained stable disease on this 
regimen.  
 
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 injection, Bortezomib (Velcade), 0.1 mg. have been met. Therefore, we 
decided that the Plan has to pay for an injection, Bortezomib (Velcade), 0.1 mg. (J9041) provided on 
October 1, 2021.  
 
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 an eternal upper limb tremor stimulator of the peripheral 
nerves of the wrist (K1018) Supplies and accessories for external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1019). 
 
You asked the Plan to pre-approve the Cala Trio wrist stimulator and monthly supplies. You say that the 
enrollee has no alternative medication options left to help manage their tremors and is unable to have surgical 
intervention. The Plan denied your request. The Plan says the Cala Trio is unproven as to the effectiveness 
since there is minimal support based on poor quality studies. 
 
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 Cala Trio wrist stimulator and 
monthly supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device has not been shown to improve function as 
the benefit with daily use is limited in duration. Impact on activities of daily living function is not clear based 
on review of the literature. 
 
 
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 Cala Trio wrist stimulator and monthly supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an eternal upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) Supplies and accessories for external upper limb tremor stimulator of 
the peripheral nerves of the wrist (K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152-59 billed for date of service October 5, 2022. 
 
You asked the Plan to pay for code 99152-59. You say that this code is supported in the medical record and 
should be separately reimbursable. The Plan denied your request. The Plan says the use of the 59 modifier to 
allow for separate payment of code 99152 is not supported in the medical record. This code is considered part 
of the primary procedure (code 45380). 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 99152-59 Our reviewer says that the 
use of the 59 modifier is not appropriate in this case. Our physician reviewer found the procedure report 
describes a colonoscopy with biopsy and sedation.  In this case, sedation services provided for GI procedures 
should be reported with CPT code G0500.  CPT 99152 is inappropriate to code for GI procedures.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152-59 billed for date of service October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found at the current level; you do not need therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week. She will not tolerate the intensity and make significant functional 
gains in a reasonable period of time in an IRF. You do not need an intensive therapy program with therapy 3 
hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 
IRF admission is not medically necessary. You need Nephrologist's care. While you may benefit from physical 
therapy, and occupational therapy, your therapy needs can be provided safely in a low intensity alternate setting 
such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc procedure (0627T). 
 
You asked the Plan to pre-approve VIA disc procedure. You say that the enrollee needs this procedure. The 
Plan denied your request. The Plan says the requested procedure 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 VIA disc procedure. Our reviewer says 
that the requested VIA Disc procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. Further studies are needed to 
demonstrate this request has beneficial outcomes as compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the reviewer found that the requested VIA Disc procedure 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 VIA disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve VIA Disc procedure (0627T).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry monitoring. 
 
You asked the Plan to pre-approve cardiovascular monitoring. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this 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 cardiovascular monitoring. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not have any indications for Holter monitoring such as 
palpitations, syncope, or pre-syncope. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiovascular monitoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve external mobile cardiovascular telemetry monitoring.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) services. 
 
You asked the Plan to pre-approve SBRT services. You say that the records provided support the need for the 
requested treatment. The Plan denied your request. The Plan says SBRT is not medically necessary for breast 
cancer oligometastases/oligoprogression. 
 
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 SBRT services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the plan for this enrollee is to treat a liver metastasis in the setting of widespread metastatic 
disease and having undergone multiple courses of brain radiation and palliative extracranial radiation, as well 
systemic therapy. SBRT was not shown to be of any benefit for oligometastases, and this patient has much more extensive disease that that. The case file has not demonstrated the necessity for SBRT which is not the 
standard of care or routine practice for treatment of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence on imaging studies 
that the fracture is less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for hyponatremia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 the enrollee is a 69-year-old who was admitted to the acute care hospital with stroke 
requiring thrombectomy, hemicraniotomy, intubation, vent support, trach placement, and PEG placement. 
Recent notes describe the enrollee as still dependent on mechanical ventilation support and not able to 
communicate, without improvement requiring ongoing fever and need for IV Keppra, antibiotics, and fluids without recent weaning attempts documented.  
1. The enrollee appears to not be improving significantly, is not yet stable, and not undergoing weaning and 
requires short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable and as it would not be 
clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.