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

 
We decided that the Plan does not have to pre-approve a Freestyle kit continuous glucose monitor (CGM) 
sensor. You asked the Plan to pre-approve a Freestyle CGM 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. 
 
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 have diabetes 
or use insulin or have a history of problematic hypoglycemia Based on this information, we decided that 
Medicare rules for coverage of a Freestyle CGM sensor have not been met.  Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle kit continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Gyrus G3 for radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve the Gyrus G3 for RFA procedure. 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 the Gyrus G3 for RFA procedure. 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 evidence that the enrollee is fully utilizing all first line 
therapies for sleep apnea, including weight loss and regular continuous positive airway pressure (CPAP) use to justify a procedure. Secondly, the currently available literature on RFA treatments for obstructive sleep apnea 
(OSA) are limited and low quality (low number). There needs to be higher quality studies showing benefit and 
safety long-term compared to other standard procedures to support the RFA procedure. Therefore, this request 
for such will be considered 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 the Gyrus G3 for RFA procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Gyrus G3 for radiofrequency ablation (RFA) procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (0117U) provided on August 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical records provided. The Plan denied your request. The Plan says that sufficient documentation 
must be submitted for this claim. 
 
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 has not provided a clear explanation regarding their 
decision to deny your request, and the Plan has not forwarded the supporting documentation which appears to 
have been included with the appeal request as an added attachment. We are unable to verify the Plan's denial as 
it appears that supporting documentation was included with the appeal but was not included in the 
documentation sent to us. Therefore, we decided that the Plan has to pay for laboratory services (0117U) 
provided on August 10, 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 pay for the levonorgestrel-releasing intrauterine contraceptive 
system (mirena) (J7298) provided on February 15, 2023. 
 
You asked the Plan to pay for Mirena. You say that this service was not for contraceptive purposes. You say 
that this is used as treatment for your diagnosis. You also say that your provider advises this is medically 
indicated for your diagnosis. The Plan denied your request. The Plan says this medication is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code J7298 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code J7298 is non-covered. Based on this information, we decided that Medicare rules for coverage of Mirena have not been met. Therefore, we decided that the Plan does not have to pay for the levonorgestrel-
releasing intrauterine contraceptive system (mirena) (J7298) provided on February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary and 
ordered by an in-network doctor. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
and infiltration of sustained release therapeutic drug (D9613). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and require these 
procedures. The Plan denied your request. The Plan says these services are not covered under the Plan's dental 
benefits. 
 
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 a 
bone replacement graft for ridge preservation (D7953) and infiltration of sustained release therapeutic drug 
(D9613).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 2, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on February 2, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an 
LTACH versus a lower level of care as their condition has stabilized and will require a multi-disciplinary 
approach for an extended period of time. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary, and the enrollee's needs can be met in the current hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is not yet stable for transfer and should only require short-term additional 
acute care services that can safely be completed at the current facility. There are no services at the LTACH that 
the enrollee requires that are not already available and covered at the current facility. Completion of treatment 
at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
  You asked the Plan to pre-approve SNF care. You say that you have no help in your home. You also say that 
you have dialysis and will not have transportation set up for at least three days. The Plan denied your request. 
The Plan says you do not meet the medical necessity criteria for the SNF admission. 
 
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 not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is not medically necessary to control the three approved power options through 
the joystick (drive interface). 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found that the enrollee has chronic medical illness, with normal range of motion and 3/5 strength in 
the upper extremity. The enrollee has adequate strength to manage standard power drive controls. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822, 95885, 95908 and 95937 billed for 
date of service December 2, 2021. 
 
You asked the Plan to pay for procedure codes 95822, 95885, 95908 and 95937. You say that these services 
were reported correctly. The Plan denied your request. The Plan says these codes are not supported in the 
medical records. 
 
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 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 codes 95822, 95885, 95908 and 95937. Our 
reviewer says that the codes reported are not supported in the medical record. Our reviewer found there are 
more appropriate procedure codes to describe/report the procedures performed in this case. 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 codes 95822, 95885, 95908 and 95937 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95822, 95885, 95908 and 95937 billed for 
date of service December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the enrollee is in extreme pain. 
There are additional medical records enclosed. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show the enrollee does not have at least three positive provocative 
maneuvers confirming the SI joint is the source of her 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 sacroiliac joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the records show that the enrollee has a diagnosis of low back muscle strain. It 
remains unclear if the SI joint is the clinical cause of pain, which previously improved with treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the tongue biopsy provided on November 29, 
2022. 
 
You asked the Plan to reimburse you for the surgical service. You say that it is your understanding that your 
policy covers in and out of network claims. You say that you were not aware that this provider had opted out of 
Medicare. You also say that you expected to be partially reimbursed at the out of network rate. The Plan denied 
your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says payment 
cannot be made for services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program.  Therefore, we decided that the Plan does not have to reimburse you for 
the tongue biopsy provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPECT (DAT) Scan (Radiopharmaceutical localization 
of tumor, inflammatory process or distribution of radiopharmaceutical agent(s), tomographic (SPECT), single 
area, single day imaging) (78803). 
 
You asked the Plan to pre-approve nuclear medicine test. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan 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 nuclear medicine test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee has suspected Parkinson's disease. He presented with a slight resting 
tremor in right lower extremity with repetitive coordinated movements in the upper extremities reduced and 
tone increased. Reflexes 3+ throughout. SPECT scan was requested. The Plan coverage criteria describes 
a SPECT scan may be used to differentiate Parkinsonian Syndromes (Parkinson Disease, Multiple System 
Atrophy, Progressive Supranuclear Palsy, Corticobasal Degeneration) from essential tremor and drug-induced 
tremor when the diagnosis remains unclear after evaluation by a neurologist, medication trials and brain 
imaging. However, initial imaging with MRI or regular CT were not completed showing need for follow-up 
with SPECT. Also, there is no indication of how findings might impact management. Therefore, this request 
for SPECT will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nuclear medicine test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SPECT (DAT) Scan (Radiopharmaceutical localization of tumor, inflammatory 
process or distribution of radiopharmaceutical agent(s), tomographic (SPECT), single area, single day imaging) 
(78803).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's medical record review shows that the enrollee had a prostate 
biopsy in August 2022 that shows Gleeson 6 prostate cancer. 
 
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 medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
Specifically, waterjet ablation of the prostate is not considered reasonable and necessary for patients with 
prostate cancer. 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 waterjet ablation of the prostate (0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network tooth extractions. 
 
You asked the Plan to pre-approve the dental services. You say that due to the enrollee's age and medical 
conditions, it would be better for them to not have to travel a longer distance. The Plan denied your request. 
The Plan says the enrollee does not have out-of-network benefits.  
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve out-of-
network tooth extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic education services to be provided by an out-of-
network (OON) provider at the in-network benefit level.  
 
You asked the Plan to pre-approve the OON diabetic education services at the in-network benefit level. You 
say that you have seen this diabetic educator since 2015 and you trust her. You say that if you went somewhere 
else you would have to drive further. You say that communication between your doctor and someone else 
wouldn't be there.  The Plan denied your request. The Plan says this is not an urgent or emergent situation. The 
Plan says that there are network providers who can supply the care needed.  
 
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 
diabetic education services to be provided by an out-of-network (OON) provider at the in-network benefit 
level.