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

 
We decided that the Plan does not have to pre-approve supply allowance used with a therapeutic CGM device 
(K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 
(K0554). 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that you appreciate a 
reconsideration of your request and grant you the CGM for your quality of life. You do not want to decline any 
further in your health. The Plan denied your request. The Plan says the enrollee is not using insulin and does 
not meet the Medicare 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 indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supply allowance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve supply allowance used with a 
therapeutic CGM device (K0553) and receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy, breast, with placement of breast localization 
device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, 
percutaneous; first lesion, including ultrasound guidance provided to the enrollee on April 29, 2022. 
 
You asked the Plan to pay for the services. You say that the diagnosis was assigned to this case based on the 
medical situation. The Plan denied your request. The Plan says this was not reported with an appropriate 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the history of "left breast mass" is not sufficient for the description appropriate for ICD-10 
coding. There was no description in the technique of the procedure nor the header which is necessary to attach 
an ICD-10 code for reimbursement. In particular, at least the quadrant of the biopsied breast is required. In 
addition, the description of the procedure did not describe whether the breast mass was palpable or seen on 
mammography/ultrasound. In summary, there was insufficient description of the anatomic location in the left 
breast in order to attach a proper ICD-10 code necessary for reimbursement. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when 
performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including 
ultrasound guidance provided to the enrollee on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the insertion of a heart rhythm monitor. You say that the enrollee cannot 
tolerate wearing a Holter monitor due to skin irritation. An implantable loop recorder would be implanted 
under her skin and help negate this issue. The Plan denied your request. The Plan says this request does not 
meet the criteria for medical necessity. 
 
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 insertion of a heart rhythm monitor. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found at issue is the appropriateness and medical necessity of implanting an 
ILR in the clinical management of this enrollee. ECG monitoring is somewhat limited because of skin irritation 
from electrode adhesive. The enrollee had no history of atrial fibrillation, nor were any significant cardiac 
arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke 
but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary 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 the insertion of a heart rhythm monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (15-21 classes) provided to the enrollee 
on July 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the record does not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document the results of a drug screen that were presumptively positive, 
or results of the screen were negative, and this negative finding was inconsistent with the patient's medical 
history, or the test was used when there was no presumptive test available, as required by the Local Coverage Determination. The records do not document that it was necessary to test for 15-21 drug classes with a 
definitive drug test. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (15-21 classes) provided to the enrollee on July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 18, 
2022, to June 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you already made a payment 
for this so it should be paid for. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $295 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan.The Plan contract says that enrollees must pay $295 copayment for 
each outpatient surgery visit in an ambulatory surgical center. You already paid $250 towards each visit leaving 
you with a remaining copayment of $45 for each visit. Therefore, we decided that the Plan does not have to 
waive the copayment for outpatient surgery provided on May 18, 2022, to June 22, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for hip and pelvic fracture after a fall. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the abdomen and pelvis; 
without contrast material (74176). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee underwent a 
wellness exam. Laboratory tests were previously performed and discussed. A CT scan of the abdomen/pelvis 
was recommended to evaluate her kidney due to abnormal laboratory results. A CT scan is not a standard of 
care for working up a slightly reduced glomerular filtration rate (GFR). Urine testing and standard imaging 
such as an x-ray or ultrasound could be considered in this case or at least a review of other more common 
causes of kidney function decline which were not discussed in the record. Therefore, without sufficient support 
made for this request, the requested CT scan of the abdomen and pelvis will be considered as not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the abdomen and pelvis; without contrast material (74176).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits and platelet rich plasma (PRP) 
injections provided from June 20, 2022, to July 18, 2022. 
 
You asked the Plan to reimburse you for the physician services. You say that this was the only provider in your 
area providing this service. You also say that you want to avoid shoulder surgery due to the bad side effects of 
anesthesia. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. 
The Plan says that payment cannot be made for services performed by a provider that has opted out of 
Medicare. The Plan also says there are 33 Medicare-certified Orthopedic surgeons in your area. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visits and platelet rich plasma (PRP) injections provided from June 20, 2022, to July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 3, 2022, to July 12, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says Licensed 
Professional Counselors are not eligible to enroll in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
May 3, 2022, to July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor. 
 
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 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 you do 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 3 continuous glucose monitor (CGM) sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
July 27, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you disagree with 
the amount you were charged for the ambulance transportation. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance transportation provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive preventive medicine reevaluation for 
cervical and vaginal cancer screening provided on July 21, 2022. 
 You asked the Plan to pay for comprehensive preventive medicine reevaluation for cervical and vaginal cancer 
screening. You say that you were not aware of the policy limit. The Plan denied your request. The Plan says 
your Plan does not cover more than one routine GYN visit every 24 months. You have reached the limit for this 
service. You received a routine pap test on July 15, 2021. 
 
The Plan contract says that the Plan covers cervical and vaginal cancer screening once every 24 months.  
 
We looked at the file and the Plans rules. The file shows that you received a routine pap test on  
July 15, 2021, therefore, you have reached the limit for this service. Based on this information, we decided that 
Plans rules for coverage of comprehensive preventive medicine reevaluation for cervical and vaginal cancer 
screening have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive 
preventive medicine reevaluation for cervical and vaginal cancer screening provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sign language or oral interpretive services, per 15 minutes, 
(T1013) provided on March 17, 2022. 
 
You asked the Plan to pay for the interpretive services. You say that denial of the cost of an American Sign 
Language (ASL) interpreter is in violation with the American Disabilities Act (ADA). You say that you require 
an ASL interpreter for medical office visits. You also say that you are not supposed to have to pay for this. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement cannot be made for language 
access services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the interpretive services have not been met. Specifically, the service in this case is not separately 
payable by Medicare. Therefore, we decided that the Plan does not have to pay for sign language or oral 
interpretive services, per 15 minutes, (T1013) provided on March 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion interspinous spacer. You say that the requested procedure is 
not experimental or investigational, based on the substantial body of published clinical literature to support the 
safety, efficacy, and durability of the Vertiflex procedure. This includes the approval from the Food and Drug 
Administration (FDA.) You say that the enrollee has failed conservative approaches to treatment. 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 the Superion interspinous spacer. Our 
reviewer says that the Superion interspinous spacer is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that a Superion spacer is considered experimental, and 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 the Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 31, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on March 31, 2022.