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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary due to 
chronic obstructive pulmonary disease. The Plan denied your request. The Plan says the records do not show 
that the ventilator is needed for the enrollee's condition. The provider is requesting a noninvasive ventilator, but 
the records do not show that the enrollee has used, and failed, a trial of CPAP or BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
was recently hospitalized with pneumonia.  ABG was consistent with chronic hypercarbic respiratory failure. 
The enrollee may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator 
when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of code 87481 billed for December 6, 2021. 
 
You asked the Plan to pay for four units of code 87481. The Plan denied your request. The Plan says the 
records do not support four units of code 87481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 four units of code 87481 Our reviewer says 
that four units of code 87481 are not supported by the records provided. Our physician reviewer found that the 
records provided only support 3 units of code 87481. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four units of code 87481 have not been met. 
 
 
  
 Therefore, we decided that the Plan does not have to pay for four units of code 87481 billed for December 6, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on July 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services (G0483) provided on July 26, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested drug is not medically necessary. 
 
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 pre-approve Zilretta. Our reviewer says that the 
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer 
found the enrollee has a diagnosis of osteoarthritis of the knee.  The Food and Drug Administration has stated 
that the requested drug is indicated as an intraarticular injection for treatment of osteoarthritis-related knee 
pain. The elements of the coverage criteria are satisfied. Therefore, the enrollee meets criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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 continuous glucose monitor (CGM). 
 
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 criteria for coverage 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 require 
frequent daily adjsutments of insulin based on blood glucose testing results. 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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says 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. 
 
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 wheelchair ramp (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 75716. The Plan denied your request. The Plan says payment for 
code 75716 is bundled into payment for code 37221.  
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 75716 
is a column II code to column I code 37221. 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 75716 billed for date of service June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the criteria. 
 
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 does not indicate that the enrollee requires 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 an admission to acute rehabilitation will help the 
enrollee regain the mobility and independence prior to this hospitalization, these needs will not be met in a 
skilled nursing facility. The Plan denied your request. The Plan says the records do not show the enrollee will 
be able to fully participate in the intensity of 3 hours of daily therapies in the IRF setting, medically necessary 
care may be provided safely in a different level of care. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services with stent placement. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe stenosis. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. The Plan follows Medicare rules. Medicare rules say that non-vascular stents 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 services. Our physician 
reviewer found that the most recent outpatient evaluation does not describe any lower extremity symptoms and 
documents palpable pedal pulses bilaterally. There is no ankle brachial index (ABI) provided demonstrating 
significant arterial occlusive disease. There is no medical record assessment provided demonstrating a plan to 
perform angiography and intervention. Incidental/asymptomatic stenosis of the common femoral artery is not 
an indication for treatment as intervention may do more harm than good. The documentation does not support 
the medical necessity of the treatments in question.   
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization services with stent placement.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment program services provided on  
August 29, 2022. 
 
You asked the Plan to pay for Opioid treatment program services. You say that you have been enrolled in the 
Medicare program to provide OTP services since January 01, 2020. The Plan denied your request. The Plan 
says individual providers cannot bill for OTP services. Payment is not allowed for this claim because it does 
not meet the opioid treatment program criteria for payment. Per CMS, we can only pay opioid treatment 
program claims for SAMHSA certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Opioid treatment program services have not been met. Therefore, we decided that the Plan does not 
have to pay for Opioid treatment program services provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet with or without 
commode opening (E0247). 
 
You asked the Plan to pre-approve a transfer bench. You say that you disagree with the denial and would like 
the plan to reconsider coverage. The Plan denied your request. The Plan says the requested transfer bench is 
considered a comfort or convenience item; hygienic equipment and should be denied because they are not 
primarily medical in nature. 
 
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 transfer bench for tub or toilet with or without commode 
opening (E0247).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the service 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 pay for the dental 
services on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence wipes (A4335). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested wipes are not covered because they are not medical in nature 
and are regularly and primarily used by persons who do not have a specific medical need for them. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes (A4335).
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 you will lose your leg if you are not 
moved to long term acute care hospital. The Plan denied your request. The Plan says the records do not show 
you have a complex wound care or would require services in LTACH and medically necessary care may be 
provided safely in a different level of care. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept device) (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested device 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental and investigational. Therefore, 
the reviewer found that the Intracept 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept device) (64628, 
64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says we 
have providers who are in-network with your health Plan. 
 
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 
physician's services 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 a blood smear interpretation (85060) billed for date of 
service July 9, 2022. 
 
You asked the Plan to pay for a blood smear interpretation. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a blood smear interpretation have not been met. Specifically, the claim at issue has been billed with 
place of service code 22, which indicates an outpatient hospital setting. The services at issue appear to have 
been furnished to a hospital outpatient in this case. Therefore, we decided that the Plan does not have to pay for 
a blood smear interpretation (85060) billed for date of service July 9, 2022.