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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device had not been reviewed by the PDAC prior to June 15, 2023. As such, this non-adjunctive 
CGM device is not eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 30 acupuncture visits billed for dates of service February 13, 
2023, to February 16, 2023. 
 
You asked the Plan to pay for 30 acupuncture visits. You say that you paid for 30 visits and should be 
reimbursed. The Plan denied your request. The Plan says an itemized bill has not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of 30 acupuncture visits have been met. 
The submitted documentation does not include an itemized bill or other records showing the specific services provided and dates of service. Therefore, we decided that the Plan does not have to pay for 30 acupuncture 
visits billed for dates of service February 13, 2023, to February 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing 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 myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT) (78452).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued inpatient psychiatric services. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 approve these services. Our reviewer says that 
continued inpatient services are not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on August 14, 2023 with Type II Bipolar disorder and moderate depression with 
anxious distress. Based on the submitted records, it is not expected that she will improve in a reasonable period 
of time, as she is not showing dangerousness to herself or others and does not have auditory or visual 
hallucinations or aggressive behaviors. It does not appear that active treatment is taking place. The services are 
not expected to improve the enrollee's condition or for the purpose of diagnosis. Continued inpatient mental 
health care is not medically necessary based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. 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 approve continued inpatient psychiatric services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral minimally invasive sacroiliac (SI) joint fusion. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presented with low back 
pain rated at three to four out of 10 and is being treated for sacroiliitis. Detailed documentation is not evident 
regarding imaging or radiographic evidence supporting a sacroiliitis pathology. Multiple other plausible pain 
generators including at the lumbosacral spine are evident. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bilateral minimally invasive SI (sacroiliac) joint fusion is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral minimally invasive sacroiliac (SI) joint fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular radiofrequency ablation (RFA) (64624).  
 
You asked the Plan to pre-approve the RFA. You say that this is medically necessary for the enrollee.  The Plan 
denied your request. The Plan says this is considered experimental for knee pain.  
 
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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy at this time. It is the subject of ongoing clinical trials. 
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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular radiofrequency ablation (RFA) (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion consultation. You say that you would like to receive all of 
your care under one roof, one facility. The request is crucial to your life, care and well-being. The Plan denied 
your request. The Plan says the requested referral is not medically necessary. Care, including a second opinion, 
is available within the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion consultation with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport wheelchair. 
 
You asked the Plan to pre-approve a transport wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no documentation that the enrollee cannot resolve his mobility 
limitations with the use of a properly fitted cane or walker. Also, there is no documentation by the ordering 
provider that the enrollee has mobility related deficiencies specifically related to activities of daily living.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 transport wheelchair. Our reviewer 
says that the enrollee does not need this item. Our physician reviewer found there is no evidence the enrollee 
requires a transport chair to complete MRADLs 
 
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 transport wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transport wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641-XU billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 87641. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this 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 87641 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
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 87641. Our reviewer says that code 87641 is not supported. Our reviewer found there are no results, positive or negative, showing that this test was done. 
Also, the record states that staphylococcus aureus was not tested for this sample. 
 
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 87641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87641-XU billed for date of service June 13, 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 utilization of the exceptional care at the inpatient 
rehabilitation unit would benefit the enrollee so that they can make a speedy recovery and then return home. 
The Plan denied your request. The Plan says an inpatient rehabilitation stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 services (99204) provided on April 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter". 
 
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 the services. Our reviewer says that the use of code 99204 is not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or high level of medical decision making. 
 
We looked at this coder'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 the services (99204) provided on April 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Breast Cancer Index test billed for date of service March 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a validated molecular assay. The Plan 
denied your request. The Plan says that the billed code cannot be verified. 
 
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 the BCI test provided was billed with CPT code 81518 as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for the Breast Cancer Index test billed for date of service March 23, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this is a billable code. The Plan denied your 
request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you had a fall and sustained an injury which is 
limiting your arm mobility. You say you must use a walker with one hand which causes balance issues, and 
your home has steps which you are not able to manage yet. The Plan denied your request. The Plan says the 
request for SNF services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93010) provided on April 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93010 is "Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only". 
 
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 the services. Our reviewer says that the use of code 93010 is 
not supported by the records provided. Our reviewer found that the documentation does not contain an 
electrocardiogram (EKG) interpretation and report for the billed date of service. It cannot be verified that this service was performed. 
 
We looked at this coder'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 the services (93010) provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator (E0748) is 
covered only if any of the following criteria are met: 
 
        Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
        Following a multilevel spinal fusion surgery (see Appendices section), or 
        Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site. 
 
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 spinal electrical osteogenesis 
stimulator. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
records do not document a failed spinal fusion where a minimum of nine months has elapsed since the last 
surgery, or a multilevel spinal fusion surgery has been performed, or a spinal fusion surgery has been 
performed where there is a history of a previously failed spinal fusion at the same site. 
 
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 spinal electrical osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).