Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on February 15, 2023. 
 
You asked the Plan to pay for the anesthesia. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service was obtained through a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the anesthesia provided on February 15, 
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 were advised the hospital will not discharge you 
as it is not currently safe unless you have SNF or further assistance with therapy services available. You also 
say that your home is not currently a safe environment to return home to. The Plan denied your request. The 
Plan says you have no current skilled nursing needs and no pain control issues that would require skilled care. 
 
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. Our reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that this is necessary to rule out atrial fibrillation in 
the setting of prior transient ischemic attack (TIA). The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
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 the ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found while the enrollee has a 
patent foramen ovale, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke, or any other apparent indication for an ILR. Therefore, the reviewer found that the 
requested ILR device 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 the ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with captains chair and 
joystick mounting bracket. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that the home evaluation was 
submitted with the original packet. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 Group 2 power wheelchair. Our 
reviewer says that the requested Group 2 power wheelchair is not medically necessary. Our physician reviewer 
found the provided documentation indicates that the enrollee is noted to be able to ambulate household 
distances. The enrollee primarily requires assistance with transfers. The enrollee is modified independent with 
daily activities without the use of a wheelchair. The documentation shows the enrollee has 3/5 motor strength 
in the upper extremities and have the ability propel a lightweight manual wheelchair. Therefore, the reviewer 
found that the requested Group 2 power wheelchair 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 a Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair with captains chair and joystick mounting 
bracket.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy and occupational 
therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you lost both of your legs and you need 
the home health therapy services.  The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented, ongoing, home health therapy needs. The enrollee is functioning at a level 
commiserate with their amputations and living arrangement. The enrollee can be managed at a lower level of 
care (i.e., home exercise program, outpatient therapy, layperson supervision). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health physical therapy and occupational therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of a new or replacement of a permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208) and an intracardiac catheter ablation of 
atrioventricular node function (93650). 
 
You asked the Plan to pre-approve cardiac resynchronization therapy with defibrillator (CRT-D) placement and 
ablation. You say that the enrollee is at risk for stroke or pulmonary issues. These procedures are medically 
necessary. The Plan denied your request. The Plan says the requested procedures 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 cardiac resynchronization therapy with 
defibrillator (CRT-D) placement and ablation. 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 
symptomatic atrial fibrillation. At issue is the medical necessity of implantation of a CRT-D coupled with 
atrioventricular (AV) node ablation in managing the enrollees atrial fibrillation. The enrollee has an ejection 
fraction of 55%. As such, guidelines would not support implant of a CRT-D. In summary, there is insufficient 
documentation to support the medical necessity for implantation of a CRT-D in this enrollees 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 cardiac resynchronization therapy with defibrillator (CRT-D) placement and 
ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve an insertion of a 
new or replacement of a permanent pacemaker with transvenous electrode(s); atrial and ventricular (33208) and 
an intracardiac catheter ablation of atrioventricular node function (93650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item is considered experimental. 
 
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 MyoPro orhosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 18, 2022, to June 
16, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
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 May 18, 2022. The NOA was not received by the Plan until June 22, 2022. 
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 
May 18, 2022, to June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee will significantly 
benefit from a genicular nerve block or coolief radiofrequency ablation. You say that the enrollee has tried and 
failed a lumbar sympathetic block, physical therapy interventions, celecoxib, and Cymbalta medications for 
their knee pain with little relief. The Plan denied your request. The Plan says the genicular nerve block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
nerve blocks and genicular nerve ablations are considered investigational and not medically necessary for the 
treatment of chronic knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0627), purchased on September 30, 
2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the item should be covered. The Plan 
denied your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0627), 
purchased on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has failed to settle with 
injection therapy, physical therapy or medical management including anti-inflammatory and analgesics. The 
Plan denied your request. The Plan says the genicular radiofrequency ablation is considered experimental and 
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 the genicular nerve block. Our reviewer 
says that the genicular radiofrequency ablation is considered experimental and investigational. Our physician 
reviewer found that genicular nerve blocks and genicular never ablations are considered investigational and not 
medically necessary for the treatment of chronic knee pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing identified with code 0013M for date of 
service April 28, 2023. 
 
You asked the Plan to pay for the CxBladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing identified with code 0013M is 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is CxBladder billed 
with code 0013M. This service is specifically not covered. Based on this information, we decided that 
Medicare rules for coverage of the CxBladder testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the CxBladder testing identified with code 0013M for date of service April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Mis 2 reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre Mis 2 reader. You say that the medical records support 
the need for the CGM.  The Plan denied your request. The Plan says the enrollee is not on insulin and does not 
have documentation of problematic hypoglycemia.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the FreeStyle  Libre Mis 2 reader. Our 
reviewer says that the FreeStyle  Libre Mis 2 reader is not medically necessary. Our physician reviewer found 
coverage criteria require low blood glucose sugar or insulin use for CGM coverage. The enrollee is not having 
low blood glucose sugar that we are told of, nor on insulin. We are not told why fingerstick meter would not 
suffice. Hence, coverage criteria are not met for CGM. 
 
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 FreeStyle  Libre Mis 2 reader have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre Mis 2 reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve infusion services. You say that this should be approved given the 
complexity, severity, and need for frequent intervention. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan and the enrollee can be treated within the Plan network. 
 
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 
infusion services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for visual electrophysiology testing provided on  
September 12, 2022. 
 You asked the Plan to pay for visual electrophysiology testing. You say that the visual electrophysiology 
testing was medically necessary. The Plan denied your request. The Plan says you did not have a qualifying 
Medicare diagnosis to support medical necessity for visual electrophysiology testing. 
 
The Plan follows Medicare rules. Medicare rules say that visual electrophysiology testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 pay for visual electrophysiology testing. Our 
reviewer says that visual electrophysiology testing is not considered medically reasonable and necessary in this 
case. Our physician reviewer found in a progress note September 12, 2022, you had an evaluation of your eyes 
not tracking well, questionable nystagmus. There is light sensitivity and headaches. Diagnoses include lack of 
coordination, unspecified disorder of visual pathways, disorders of binocular movement, visuospatial deficit, 
dry eye syndrome, abnormal visually evoked potential, visual field defect, and hypermetropia. You were not 
documented to have any of the conditions listed the Medicare LCD for coverage of visual electrophysiology 
testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of visual electrophysiology testing have not been met. Therefore, we decided that 
the Plan does not have to pay for visual electrophysiology testing provided on September 12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that this is indicated for syncope and history of 
atrial fibrillation/flutter. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
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 the ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has had syncope with resultant subdural hematoma, with negative 2-week 
ambulatory electrocardiogram (ECG) monitor. There remains a suspicion of an arrhythmic etiology, as the 
enrollee has a history of same. Therefore, the reviewer found that the requested ILR device to assess for 
suspected arrhythmic etiology of syncope would be 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 ILR device have been met. Therefore, we decided that the Plan has to pre-
approve an implantable loop recorder (ILR) device.  
 
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.