Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve zoledronic acid. 
 
You asked the Plan to pre-approve zoledronic acid. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that drugs dispensed by a pharmacy are not covered. 
 
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. We find that the Plan did not substantiate that the requested drug would not be 
buy and bill. Therefore, we decided that the Plan has to pre-approve zoledronic acid.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensor kit.  
You asked the Plan to pre-approve Freestyle Libre. You say that the enrollee is reluctant to do the finger sticks 
and has been compliant with the Freestyle Libre since the end of 2020. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for coverage. 
 
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 Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-
approve Freestyle Libre 2 sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to be discharged to an IRF. You 
say that the enrollee will have a shorter length of stay and a better outcome with an IRF admission. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can 
be met at an alternate 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80305 and 80307 billed for date of service 
January 3, 2023.  
 
You asked the Plan to pay for procedure codes 80305 and 80307. The Plan denied your request. The Plan says 
the services are not payable as billed. 
 
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. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the MUE for CPT code 80307 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 80307 have not been met. 
 
In this case, we have confirmed that code 80305 is a column II code to column I code 80307 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80305 
and 80307 billed for date of service January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excess skin removal. 
 
You asked the Plan to pre-approve a surgery. You say that the enrollee needs this excess skin removal. The 
Plan denied your request. The Plan says this procedure is considered cosmetic and 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 a surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has had a history of breast reconstruction in the setting of 
breast cancer.  The record provided is insufficient to establish that the elements of the coverage criteria for 
coverage to be available for the requested service have been satisfied. The record provided is insufficient to 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not have 
to pre-approve excess skin removal.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee unilateral 
primary osteoarthritis. Failure of conservative management is documented in the records. She received a total 
of six bilateral Zilretta injections from September 7, 2021, to April 27, 2023. There is insufficient support in 
the medical literature for the use of repeat Zilretta. The servicsesare not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 5, 2022, to 
September 15, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. 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 September 5, 2022. The NOA was not received by the Plan until January 
30, 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 September 5, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection provided on March 29, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the injection. You say that you are appealing the denial with supporting medical 
records. The Plan denied your request. The Plan says this service 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 enrollee's POS benefit only applies to covered routine dental 
services. 
 
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 the injection provided on March 29, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient T8 Kyphoplasty (22513).  
 You asked the Plan to pre-approve Kyphoplasty. You say that the enrollee has exhausted conservative 
treatment and is still in pain.  The Plan denied your request. The Plan says medical necessity coverage criteria 
is not met as the pain is multifactorial with multilevel disc disease in the thoracic spine.  
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty is covered when the criteria in the rules 
section of this letter are met.  
 
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 service is not medically necessary. Our physician reviewer found that detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic deformity, 
or a severe impact on her daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration 
of plausible other causes of pain. Therefore, the enrollee does not meet the LCD criteria for coverage of 
Kyphoplasty. 
 
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 outpatient T8 Kyphoplasty (22513).
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. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 that the enrollee is receiving the appropriate care in the current acute care setting. The 
documentation does not support that LTACH services are appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee goal is to return home to their prior level 
of function with increased independence and improved quality of life. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring system (K1024, K1033). 
 
You asked the Plan to pre-approve the Koya Dayspring system. You say that you are only manufacturer and 
sole provider of the Dayspring System The Plan denied your request. The Plan says the Koya Dayspring 
System is non-covered because they are not primarily medical in nature and does not meet the definition of 
durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve the Koya Dayspring system (K1024, K1033).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 1, 2023, to 
March 2, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted on January 5, 
2023. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied. The Plan says that although you contend you submitted the NOA on January 5, 2023, 
there is no evidence of the NOA being submitted until April 20, 2023.  
 
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 January 2, 2023. The NOA was not received by the Plan until April 23, 
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 February 1, 2023, to March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS) services.  
 
You asked the Plan to pre-approve TMS services. You say that the records provided support the need for the 
treatment in dispute.  The Plan denied your request. The Plan says the requested treatment is considered 
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 TMS services. Our reviewer says that 
TMS services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found documentation shows that the enrollee was hospitalized from June 10, 2023, to June 16, 2023, with 
diagnoses of bipolar disorder, panic disorder and post-traumatic stress disorder. There is a lack of high-quality 
evidence, and there is no consensus on using TMS for bipolar disorder.   Although a prospective observational study suggests that bipolar depression may also be amenable to deep 
TMS, its efficacy is not known due to the dearth of high-quality studies. Overall, the records in this case do not 
fully support that TMS meets Medicare criteria for safe and effective and 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 TMS services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Transcranial Magnetic Stimulation (TMS) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit and services provided on December 
13, 2022. 
 You asked the Plan to pay for the outpatient office visit and services. You say that this claim should be 
processed for payment as the Plan has paid the other claims that were submitted with dates of service in 
December of 2022. You also say that this enrollee was not in hospice care when this visit was made. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the outpatient office visit and services provided on December 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) assay (84443) 
provided on November 10, 2022. 
 
You asked the Plan to pay for the TSH assay. You say that you asked for annual exam with no additional 
charges. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the TSH assay, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
thyroid stimulating hormone (TSH) assay (84443) provided on November 10, 2022.  
 
Your complaint about potentially being given misinformation from the provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.