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

 
We decided that the Plan has to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor 
(A9276). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM sensor. You say that the requested glucose 
monitoring system is necessary to treat the enrollee's diagnosis. The Plan denied your request. The Plan says 
that the requested sensor does not meet the criteria required for approval. 
 
The Plan must follow 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 Freestyle Libre 3 CGM sensor. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has 
fibromyalgia and is unable to use a fingerstick meter. She has used Metformin and Jardiance. The enrollees 
glycated hemoglobin (A1C) is above the goal at 8%. The enrollee has tried Ozempic and Trulicity and cannot 
tolerate. Although she is on medications that do not cause low blood glucose sugar (BGS); her provider feels it 
is important to use a CGM to help improve her blood glucose control. It is reasonable to approve the CGM 
sensor at this time. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 3 CGM sensor have been met. Therefore, we 
decided that the Plan has to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor 
(A9276).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services may be provided in an alternate 
setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for cardiac arrest, respiratory failure, chronic obstructive pulmonary disease, and influenza. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee has in the past been intolerable of 
both continuous positive airway pressure (CPAP) and BIPAP, therefore, the ventilator is medically necessary. 
The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel 
positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has chronic obstructive pulmonary disease (COPD), interstitial lung disease, and pulmonary 
hypertension. The enrollee was recently hospitalized with an exacerbation of COPD and interstitial lung 
disease.  An arterial blood gas on December 9, 2023 was consistent with acute on chronic hypercarbic 
respiratory failure. Pulmonary function testing in April 2022 was consistent with combined restrictive and 
obstructive lung disease, with air trapping. The enrollee may benefit from BiPAP with volume assurance 
during sleep as an outpatient. The records do not show this has been tried and failed as an outpatient. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this rehabilitation to get back to prior level 
of functioning. The Plan denied your request. The Plan says the records do not show that you need a medical 
team to manage your health care decisions. The Plan says your needs can be met at a lower 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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. You can 
receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services due to medical necessity. The Plan denied your request. The Plan says the IRF services do 
not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for tracheitis. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF stay from April 1, 2022, through April 30, 2022. 
 
You asked the Plan to pay for the SNF stay. You say that the enrollee should not be responsible for the 
copayment for this SNF stay. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1-20; $188 copayment per day for days 21-100 and there is a $4,900 
deductible which applies to certain items and services. 
 
The enrollee has been asked to pay a $2,350 for the SNF stay. This item/service falls within the skilled nursing 
facility (SNF) care benefit category. The enrollee had met the $4,900 deductible, however, there is still a 
$2,350 enrollee responsibility. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for the SNF stay from April 1, 
2022, through April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) additional office visits (99215) with an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve additional office visits. You say that the enrollee is a long-standing patient 
of the requested provider since 2010. The enrollee has an extensive and complicated neurological condition so 
transferring care to another provider is not an option at this time. The Plan denied your request. The Plan says 
there should be ample time to establish with another provider as the enrollee has been on a 6 month follow 
schedule. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 additional office visits. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no medical indication 
for out of area neurology services. The review has determined that the enrollee is not currently receiving any 
active treatment and/or medical management of her conditions that makes it medically necessary for this 
enrollee to continue care with the out-of-network neurology provider as requested. There is not anything 
unique about this enrollees condition that would make it medically necessary for her to continue care with the 
out of network provider. The plan has shown that they have in-network neurology specialists who have the 
qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of 
the enrollees condition. The enrollees medical management and/or follow-up care can be safely transitioned 
to an in-network neurology specialist 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 additional office visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three (3) additional office visits (99215) with an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adempas. 
 
You asked the Plan to pre-approve the medication. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Adempas.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for thrombophilia testing for the Factor 
V Leiden (FVL) variant in the F5 gene and the 20210G>A (G20210A) variant in the F2 gene. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Medicare criteria for coverage of the requested testing 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the records provided do not support that there are any unusual 
circumstances where the requested testing will change clinical management of the enrollee. 
 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene 
and the 20210G>A (G20210A) variant in the F2 gene.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is truly the 
only solution, as no other procedure ablates the basivertebral nerve which is the source of the chronic low back 
pain. The Plan denied your request. The Plan says the request 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 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 pain is not clear. There is no magnetic resonance imaging (MRI) 
showing only Modic changes without facet degenerative joint disease or stenosis. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for office visits to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an in-network exception for office visits to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
an in-network exception for office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a male vacuum erection system (L7900). 
 
You asked the Plan to pre-approve a male vacuum erection system. You say that the item is necessary. The 
Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices (L7900) and related 
accessories (L7902) are statutorily non-covered (see related Policy Article for additional details). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a male vacuum erection system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a male vacuum erection system (L7900).