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

 
We decided that the Plan does not have to pre-approve a CGM and the supply allowance. 
 
You asked the Plan to pre-approve a CGM and the supply allowance. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and the supply allowance. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that there is no 
evidence that you have low blood sugar or use insulin. 
 
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 CGM and the supply allowance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CGM and the supply allowance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87631) and additional resources 
(99072) billed for date of service August 10, 2022. 
 
You asked the Plan to pay for infectious-agent testing and additional resources. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. The Plan also says that procedure code 99072 
is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim for infectious-agent testing does not show that 
the required unique identifier was reported. Based on this information, we decided that Medicare rules for 
coverage of infectious-agent testing have not been met. Additionally, we find that procedure code 99072 has a 
status indicator of B on the Physician Fee Schedule. This means that procedure code 99072 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of additional resources have 
not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent testing (87631) and 
additional resources (99072) billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1019, K1018) 
 
You asked the Plan to pre-approve a Cala Trio nerve stimulator device. 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 while electric nerve stimulation has been employed to 
control chronic intractable pain for some time, its use in the treatment of motor function disorders, such as 
multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been verified by 
scientifically controlled studies. 
 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 Cala Trio nerve stimulator device. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of 
peripheral nerve stimulators in the treatment of motor function disorders, such as multiple sclerosis and 
essential tremor, is a recent innovation, and the medical effectiveness of such therapy has not been verified by 
scientifically controlled studies with long duration follow-up. The device is deemed experimental at this time 
and therefore, the request is deemed not medically reasonable and 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 Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1019, K1018)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
24, 2022.  
 You asked the Plan to pay for procedure code 99291. You say that there were multiple exams on the date of 
services, and all should be paid. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is one unit. The MAI value for this code is 2. You billed one unit of 
this code on the claim at issue, but one unit of this code has previously been paid on a separate claim from the 
same provider. Based on this information, we decided that Medicare rules for coverage of procedure code 
99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 
billed for date of service November 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 31, 2022, to 
November 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 31, 2022. The NOA was not received by the Plan until January 24, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 31, 2022, to November 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional two hundred and four (204) non-emergent, 
routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation due to having dialysis three times a week. The Plan denied your request. The Plan says you have 
used eighty-four (84) one-way trips of the 60 allowed by the Plan. You have exceeded the benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional two hundred and four (204) non-emergent, 
routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication of a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CardioMEMS device is still considered an investigational device and not recommended by any 
of professional societies/association heart failure management guideline. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77523). 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. There is nothing in the records that suggests that standard 
dosimetric constraints cannot be met with a non-proton-based treatment, and it is not plausible that proton 
therapy would be needed to meet these constraints. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77523).
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 meets the admission guidelines. The 
Plan denied your request. The Plan says the enrollee does not have complex rehab, medical, and nursing needs. 
Services needed may be provided safely in 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 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 enrollee's 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (64415) provided on November 4, 2022. 
 
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the provider in this case is a registered nurse (RN). The Plan says that a RN is not 
eligible to enroll in Medicare. The Plan also says that payment cannot be made for services rendered by a 
provider that is not eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the injection (64415) provided on 
November 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on October 22, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the 
information needed to consider this charge was not submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the information needed to consider this charge was not 
submitted. However, review of the case file shows that medical records and the relevant documentation was 
submitted. The Plan has not provided specific rationale as to what is missing for a determination to be made. 
Without supporting documentation and rationale, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the lab services provided on October 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested sacroiliac injection is not medically necessary based on the Medicare LCD 
coverage criteria.  
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical value and effectiveness of an SIJ injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature.  In this case, there is no 
documentation on physical examination of tenderness to the SI joint and no mention of SI provocative testing 
being completed with positive findings. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on August 13, 2022. 
 
You asked the Plan to pay for the emergency services. You say that you feel that this is a legitimate claim for 
emergency care.  The Plan denied your request. The Plan says sufficient information was not provided by the 
facility, including a correctly billed claim.  
 The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for services provided 
by an emergency room that is not affiliated with a hospital, except for those facilities which have enrolled as a 
temporary hospital under the COVID-19 waiver.  
 
We looked at the file and Medicare rules. Review of the file shows that the provider at issue is not affiliated 
with a hospital. There is no evidence that the facility enrolled in Medicare as a temporary hospital. If the 
facility is enrolled through the waiver, they are required to submit a claim to your Medicare plan. Based on this 
information, we decided that Medicare rules for coverage of the emergency services have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency services provided on August 13, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on January 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (64483) provided on the same date of service. 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 drugs (J3490) provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code B4197 billed for date of service January 14, 
2023, to January 19, 2023.  
 
You asked the Plan to pay for procedure code B4197. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1.  
 
In this case, the MUE for code B4197 is 1. The MAI value for this code is 1. You billed 3 separate claim lines 
with 3 units of this code per line, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure code B4197 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code B4197 billed for date of service January 14, 2023, to January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication that the enrollee is enrolled in a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) and core buildup (D2950). 
You asked the Plan to pre-approve the dental services. You say that your fillings are starting to decay, and you 
would like to use your $2,500 maximum benefit for this needed service. The Plan denied your request. The 
Plan says these services are not covered under your benefit plan, and the annual maximum applies to covered 
benefits except preventive and diagnostic services. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2750) and core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390). You asked the Plan to pre-approve an oxygen concentrator. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says that the enrollee received an oxygen 
concentrator on January 27, 2017. The enrollee used the device for thirty-six (36) months. The rental period is 
capped.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The limited records submitted are a bit confusing. The records show that the 
enrollee received an oxygen contractor on January 27, 2017. The equipment was capped by January 27, 2020. 
According to policy article A52514, the RUL for oxygen equipment is 5 years. The enrollee would be eligible 
for oxygen equipment as of 2022. There are no records showing the enrollee received oxygen equipment in 
2022. We requested information from the Plan explaining that the records submitted contradicted Medicare 
rules. No additional records were submitted by the Plan. Therefore, we decided that the Plan has to pre-approve 
an oxygen concentrator (E1390).  
 
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.