Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2, L3, and L4 Kyphoplasty. 
 
You asked the Plan to pre-approve Kyphoplasty. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty may be covered under certain 
circumstances. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Kyphoplasty. Our reviewer says that 
the enrollee does not meet the indications for this procedure and does meet the contraindications for this 
procedure. Our physician reviewer found that detailed documentation is not evident regarding acute or subacute 
fractures at all of the requested levels for the kyphoplasty. There is no documentation of a progression of the 
body height loss at all levels, greater than 25% vertebral body height loss at all levels, kyphotic deformity, or a 
severe impact on daily activities. Furthermore, detailed documentation is not that the current back pain is 
primarily due to the identified acute or subacute vertebral fractures. There is MRI corroboration of other 
plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2, L3, and L4 Kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
Kit 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM Kit 2 sensor. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre CGM Kit 2 sensors have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) Kit 2 Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy and an esophagogastroduodenoscopy 
provided on May 9, 2023. 
 
You asked the Plan to pay for the colonoscopy and esophagogastroduodenoscopy. The Plan denied your 
request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 
authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a colonoscopy and an esophagogastroduodenoscopy provided on 
May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies.. You say that the requested CGM is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria was not 
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 the CGM and related supplies. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires low blood sugars or insulin use. This enrollee is not having low blood sugars and is 
not taking insulin. Although the enrollee is advised to check blood sugars 3 times a day and a CGM would help 
with this, the coverage criteria are not 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 CGM and related supplies. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 52 additional trips. 
 
You asked the Plan to pre-approve 52 additional trips. You say that the enrollee has kidney dialysis three times 
per week, is out of trips, and has no way to get to dialysis. The Plan denied your request. The Plan says the 
enrollee's benefit plan does not cover more than 40 one-way trips. 
 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 up to 40 one-way 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 52 additional trips.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) G0318. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 99350.  
 
You asked the Plan to pay for practitioner services provided on March 14, 2023, billed with procedure codes 
99350 and G0318. You say that the claim is billed correctly and should be paid. The Plan says that the number 
of units billed exceeds the maximum allowed.  
 
We decided that the Plan has to pay for the services described by procedure code(s) G0318.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) G0318.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99350. 
 
The Plan follows Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
We looked at the file, and Medicare rules. In this case, the MUE for CPT code 99350 is 1. The MAI value for 
this code is 3. You billed 2 units of this code, exceeding the MUE. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the services described by 
procedure code(s) 99350 have not been met.  Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99350. 
 
 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Liver Multi Scan (0648T). 
 
You asked the Plan to pre-approve a Liver Multi Scan. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 a Liver Multi Scan. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee, who has a history of fatty liver disease, has been referred for a Liver Multi 
Scan. However, Liver Multi Scan is not standard of care and 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 Liver Multi Scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Liver Multi Scan (0648T).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve the drug. You say that you have pain in your left shoulder and the injections 
are the only thing that helps. The Plan denied your request. The Plan says that the step therapy requirements 
have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found that you have not tried and failed the Plan's 
required drugs Euflexxa, Synvisc and Synvisc-One. Also, there is no indication that the Plan's required drugs 
would likely be less effective or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you are requesting an additional 57 miles for a total of 107 miles and your 
benefit only allows 50 miles. The Plan also says you have exceeded your 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 up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4220, B4224) provided on April 25, 
2023 to May 1, 2023  
 
You asked the Plan to pay for the nutritional supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. No itemized patient 
receipt was provided showing these specific items were delivered. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for nutritional supplies (B4220, B4224) provided on April 25, 2023 to May 1, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 26, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation for your physical therapy visits and other doctor's visits. You do not have alternate transportation 
and you cannot take public transportation due to your back and neck injuries. The Plan denied your request. 
The Plan says you have exhausted your benefit limit for 2023. 
 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 additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
March 6, 2023, through March 13, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
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 the pneumatic compression device (E0675) provided on March 6, 2023, through March 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 29, 2022, 
through January 26, 2023, billed with payment code 1HB21. 
 
You asked the Plan to pay for the home health services as billed. You say that this correct HIPPS code was 
billed and should be paid. The Plan denied your request. The Plan says the HIPPS code was changed from what 
was billed as the diagnosis code E11.40 is not supported.  
 
The Plan follows Medicare rules. Medicare rules say that payment for home health services is made based on 
consideration of the patient's diagnoses which must be supported in the records. 
 
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 home health services as billed. Our 
reviewer says that the reported secondary diagnosis code is not supported and should not be considered for 
determination of the HIPPS code. Our physician reviewer found in the face-to-face encounter, the provider 
noted that the enrollee had both type II diabetes and Guillain-Barre syndrome. Two days later, the home health 
paperwork noted that the patient had type II diabetes with diabetic neuropathy and Guillain-Barre Syndrome 
(GBS). It is unclear why the complication of neuropathy was added to the diagnosis of type II diabetes. While 
GBS is a neurologic condition, it is not diabetic neuropathy. There is no evidence that the enrollee had diabetic 
neuropathy, or that she received home health service specifically directed at type II diabetes with diabetic 
neuropathy. As such, the billing of E11.40 is not supported. 
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from December 29, 2022, through 
January 26, 2023, billed with payment code 1HB21.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the IRF admission. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. You can receive further services at a lower level of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver ultrasound with elastography. 
 
You asked the Plan to pre-approve a liver ultrasound with elastography. You say that the requested liver 
ultrasound with elastography is medically necessary. The Plan denied your request. The Plan says this test is 
not covered for surgery clearance for gastric bypass. We may cover this testing when records show the doctor 
is following up on primary sclerosing cholangitis or show the need to distinguish hepatic cirrhosis from non-
cirrhosis and there is a diagnosis of hepatitis C or other chronic liver diseases (such as hereditary 
hemochromatosis, non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)). 
Records do not show these conditions. 
 
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 a liver ultrasound with elastography. Our reviewer says that the requested liver ultrasound with elastography is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that ultrasound with elastography is recommended 
only when there is concern for advanced chronic liver disease. While you have  risk factors for chronic liver 
disease, the medical documentation does not specifically state why advanced liver disease is suspected or why 
ultrasound with elastography would be 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 liver ultrasound with elastography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a liver ultrasound with elastography.