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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
for the enrollee. 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(CPT code(s) 36475 and 36476). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show you do not have 
documentation of the necessary Medicare 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 the services. Our physician reviewer 
found the services are not necessary because the LCD criteria have not been met. 
 
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 pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency; first vein treated (CPT code(s) 36475 and 36476).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87633) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the respiratory infectious agent detection, CPT code 87633 (12-25 targets) is non-
covered by Medicare and excluded from coverage. The Plan states use is restricted to when more limited panels 
would not be medically appropriate (e.g. patient critically ill, etc.). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met.  Respiratory virus laboratory detection (eg. adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes; is not covered. CPT 87633 
(12-25 targets) is used when more limited panels would not be medically appropriate (e.g., patient critically ill, 
etc.). Use is restricted to when more limited panels would not be medically appropriate (e.g. patient critically 
ill, etc.) This is not a COVID-19 screening test. This is not an emergency test. Therefore, we decided that the 
Plan does not have to pay for the laboratory service (CPT code 87633) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision eyewear and services (V2206, V2020, 
92004, 92015, 92025, 92132, 92134, 92250, 92285, 92341) provided by an out-of-network (OON) provider on 
January 20, 2021. 
 
You asked the Plan to pay for the OON routine vision eyewear and services. You say that you are contracted 
with the facility to provider vision care and are unable to request prior authorizations before rendering services. 
The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan may cover these services when rendered by a participating provider.  
 
We looked at the file and the Plan's rules. The eyewear and vision services were rendered by an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the OON routine vision eyewear and 
services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision 
eyewear and services (V2206, V2020, 92004, 92015, 92025, 92132, 92134, 92250, 92285, 92341) provided by 
an out-of-network (OON) provider on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says a setting that 
could be delivered by a BiPAP is not covered. 
 
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 physician 
reviewer found that you have COPD, with a recent hospitalization for a COPD exacerbation, with acute on 
chronic hypercarbic respiratory failure. You may benefit from BiPAP with AVAPS and a backup rate during 
sleep. However, Medicare does not cover a home ventilator when used as a BiPAP.  A BiPAP device has not 
been tried at home. Therefore, a home ventilator is 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a bunionectomy and a hemi-implant. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
enrollee does not have severe disabling symptoms and has not failed conservative medical management. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested services. Our physician 
reviewer found that it is well established that this enrollee is suffering with a painful bunion deformity as well 
as significant osteoarthritis to the first metatarsal phalangeal joint (MPJ) on the right side. Imaging reveals 
diminished joint space, with osteoarthritic changes and osteophyte formation surrounding first MPJ right side. 
The enrollee has failed conservative treatments including ice, rest, heat, anti-inflammatory medications, and 
alteration in shoe gear. A Keller type bunionectomy with Vilex hemi implant placement to the first MPJ is a 
well-accepted and standard of care surgical procedure for this type of musculoskeletal pathology. It appears 
that both physical exam and imaging confirm the diagnosis of osteoarthritis to the first MPJ. Therefore, the 
requested services are medically reasonable, necessary, and indicated for the enrollees 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a bunionectomy and a hemi-implant.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require an intensive and coordinated interdisciplinary approach to rehab. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for osteomyelitis and a stage 4 pressure ulcer. There are no 
complex nursing or rehabilitation needs. The complexity of your nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided August 24, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you had your wife transport you to the 
emergency room because it was not far away, and you wanted to save ambulance transport expenses. The Plan 
denied your request. The Plan says this service is not covered when there is no transport.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special study of the upper or lower extremity (arms or 
legs) arteries (CPT code 93922). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the documentation provided does not support the request for the extremity study; 
therefore, it is not reasonable or medically necessary and does not meet LCD 33627 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 the service. Our physician reviewer 
found the documentation does not support the medical necessity of the arterial testing in question. There is 
inadequate documentation of the pulse examination on which to base the need for additional testing. 
Additionally, the patient had a completely normal exercise ABI study less than a year ago. The patients history 
of clots was venous in nature not arterial. The health plans request that a bedside ABI, something that can 
easily be performed with a Doppler probe and blood pressure cuff be demonstrated to be abnormal prior to 
ordering a formal arterial study, in the absence of more clear clinical documentation is not unreasonable. 
Unable to overturn the denial on the basis of medical necessity. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve special study of the upper or lower extremity (arms or legs) arteries (CPT code 93922).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.  
 PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oximeter (E0445), provided on November 5, 2021. 
 
You asked the Plan to pay for the oximeter. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that Oximeters (E0445) and replacement probes 
(A4606) will be denied as non-covered because they are monitoring devices that provide information to the 
treating practitioner to assist in managing the beneficiarys treatment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pay for the 
oximeter (E0445), provided on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 24301-RT billed for date of service 
September 1, 2021. 
 
You asked the Plan to pay for procedure code 24301-RT. You say that the medical record supports payment for 
this code. The Plan denied your request. The Plan says this procedure code is not supported in the medical 
record. 
 
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 24301-RT is muscle or tendon transfer, any type, upper 
arm or elbow, single (excluding 24320 - 24331). 
 
 We asked our coder 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 procedure code 24301-RT. Our reviewer says that this 
procedure code is not supported by the medical record. Our reviewer found the operative report does not 
describe a muscle or tendon transfer.  The operative report describes carpal tunnel release with cubital tunnel 
release, and this procedure would not be reported as a muscle or tendon transfer.  To cite the operative report, 
"Attention was turned to the right elbow.  Blunt dissection deep through subcutaneous tissues with full-
thickness skin flaps developed.  Jut superficial to the fascia, medical antebrachial cutaneous nerve identified 
and protected throughout the procedure.  Posterior to the medial epicondyle, ulnar nerve identified.  It was then 
tracked proximally and released into the distal portion of the arm".  The operative report does not describe 
muscle or tendon being transferred, and therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 24301-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 24301-RT billed for date of service September 1, 2021.
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 enrollee's care cannot be accomplished at a lower 
level of care. The Plan denied your request. The Plan says the enrollee's ongoing needs can be provided at a 
lower 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 physician reviewer found 
that the enrollee was admitted to the acute care hospital bacteremia and congestive heart failure. The 
complexity of the enrllees nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not receiving appropriate care and need an 
IRF admission. The Plan denied your request. The Plan says an intensive rehabilitation program is not 
medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: 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. You say that you test multiple times daily. The Plan 
denied your request. The Plan says the device for monitoring is not considered reasonable and necessary. 
 
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 you perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, or require 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5011), provided on September 29, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your 
request. The Plan says you did not obtain this item through a Plan provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only obtained through a Plan provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5011), provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breo Ellipta. 
 
You asked the Plan to pre-approve Breo Ellipta. You say that the enrollee has tried Advair with poor results. 
The Plan denied your request. The Plan says this drug is not covered for the enrollees condition by Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Breo Ellipta.  
 
 Benefits for Breo Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.