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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee has an extensive history with atrial 
fibrillation. You say that the enrollee has had two successful ablations which both reverted back to atrial 
fibrillation despite antiarrhythmic medication, cardioversion and ablation therapies. You also say that the 
requested service would provide a better understanding of potential underlying causes for reverting back to 
atrial fibrillation. The Plan denied your request. The Plan says the provided records do not support any apparent 
indicate for an implantable cardiac loop recorder. The Plan also says there is not record the enrollee tried and 
failed an external heart monitor. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder (ILR) is used when 
syncope is thought to be cardiac-related but is too infrequent to be detected by either a Holter monitor or a 
traditional pre-symptom memory loop recorder (MLR). 
 
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 an ILR. Our reviewer says that the 
requested ILR is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has had 3 unexplained syncope events over the preceding one year. The reviewer also found that the documentation does not indicate cryptogenic cerebrovascular accident (CVA). Therefore, the 
reviewer found that the requested ILR 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device.. You say that without this surgery 
it will greatly affect the quality of live for the enrollee. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found medical studies haven't proven that the service/item is 
helpful for treatment ofor the enrollee's health problem.  
 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 Vertiflex Superion Interspinous device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (33285).  
You asked the Plan to pre-approve the ILR. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 the ILR. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an implantable cardiac monitor (ICM). In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ICM 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 the ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop reader (ILR) (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99310) provided on November 2, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 99310 is not supported in the medical record. Specifically, place of service (POS) 13 is 
not a valid place of service for this code. Based on this information, we decided that Medicare rules for 
coverage of the nursing facility care have not been met. Therefore, we decided that the Plan does not have to 
pay for nursing facility care (99310) provided on November 2, 2022.
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 CGM. 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. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CGM. Our reviewer says that you do 
not need this medical item. Our physician reviewer found there is no mention of problematic hypoglycemia or 
insulin use in the medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that this procedure improves the quality of 
life for the enrollee. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain has not been made clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Alpha Stimulator (E1399). 
 
You asked the Plan to pre-approve an Alpha Stimulator. You say that you feel this device would be an effective 
instrument to use without the side effects of oral medication and the risk involving injected steroids. You also 
say that you feel not having the Alpha Stimulator is limiting your daily activities and its detrimental to be 
taking anti-inflammatory and pain medication daily. The Plan denied your request. The Plan says the efficacy 
of Alpha Stimulator for the treatment of chronic pain has not been established in peer reviewed literature and is 
considered experimental/investigational in nature. 
 
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 an Alpha Stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current literature advises that further studies are necessary in order to delineate the 
true effectiveness of alpha stimulation for the treatment of pain. Most studies are performed on the treatment of 
anxiety and depression. Our reviewer found that regardless, although it is understandable that you want to 
avoid potential side effects of medication and corticosteroid injections, it is unclear whether you have 
undergone more conservative treatments including bracing and physical therapy. The medical documentation 
certainly does not advise that alpha stimulation is as beneficial as available medically appropriate alternatives. 
Our physician reviewer found that therefore, the requested alpha stimulation is not medically reasonable or 
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 an Alpha Stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Alpha Stimulator (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyelid surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON eyelid surgery. You say that you are only a mile away from the 
requested OON provider. You say that you do not drive.  The Plan denied your request. The Plan says there are 
in network facilities in your service area that can accommodate you.  
 
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 
eyelid surgery to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says the enrollee is 
enrolled in a clinical trial. The Plan also says that coverage of the requested drug would be deemed a routine 
cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Opdivo as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Opdivo (J9299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) and a core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that this is necessary. The Plan denied your 
request. The Plan says the radiograph does not show large decay requiring replacing a significant amount of the 
tooth or decay under existing crown. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
   
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 dental services. Our physician 
reviewer found the limited documentation is insufficient to support that a crown (D2740) and a core buildup 
(D2950) on tooth #2 are medically reasonable and necessary for the enrollee in this case. There is not clear 
documentation of significant dental decay or crown loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750) and a core buildup (D2950).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage. 
 
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 Eylea. Our reviewer says that you do 
not meet the coverage criteria for Eylea. Our physician reviewer found the Plan requires a trial of Avastin 
(bevacizumab) before they will approve the requested drug. In this case, you have not tried and failed the 
required drug. Our reviewer also found that there is no documentation provided indicating that the Plans 
required drug would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the order for a high frequency chest wall 
oscillation system is reasonable and medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval for a high frequency chest wall oscillation system. 
 
 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that a 
high-frequency chest wall oscillation device is not medically necessary. Our physician reviewer found the 
enrollee has COPD with a chronic productive cough. The records do not include a CT scan documenting 
bronchiectasis, and there is no diagnosis of cystic fibrosis or neuromuscular disease. Our reviewer also found 
that this device has not been shown to be safe and effective in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high-frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery (E1399). 
 
You asked the Plan to pre-approve a backup battery. You say that you need this item for travel. The Plan 
denied your request. The Plan says this item is not covered for use outside of the home or for convenience. 
 
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 pre-approve a backup battery (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial culture billed with code 87086 for December 5, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 pay for the bacterial culture 
billed with code 87086 for December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there was no home evaluation submitted to determine if your home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the POV. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) may be covered 
if there is adequate access between rooms, maneuvering space, and surfaces for the operation of the POV. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is very symptomatic. You say that the 
enrollee's cancer growth is rapid. You also say that this is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the requested use of Keytruda is not supported by any of the above compendia, by 
two published articles, or by evidence-based guidelines/other standards of medical practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305, 88341, 88342, and 88360, billed for 
date of service December 5, 2022.  
 
You asked the Plan to pay for procedure codes 88305, 88341, 88342, and 88360. The Plan denied your request. 
The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that 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.  
 
In this case, the MUE for CPT code 88305 is 16. You billed 17 units of this code, exceeding the MUE. The 
MUE for CPT code 88341 is 13. You billed 27 units of this code, exceeding the MUE. The MUE for CPT code 
88342 is 4. You billed 17 units of this code, exceeding the MUE. The MUE for CPT code 88360 is 6. You 
billed 12 units of this code, exceeding the MUE. The MAI value for these codes is 3. 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 procedure 
codes 88305, 88341, 88342, and 88360, have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88305, 88341, 88342, and 88360, billed for date of service December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2023, billed 
with codes 87481, 87511, 87556, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say the test panel is a single test with multiple components and 
is characterized by a single unit of service. 
 
 
 We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 3, 2023, billed with codes 87481, 87511, 87556, 87641, 87653, and 87798.