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

 
We decided that the Plan has to pre-approve a split night sleep study (95811). 
 
You asked the Plan to pre-approve a split night sleep study. The Plan denied your request. The Plan says that a 
repeat in-lab sleep study is not needed since the patient's OSA was confirmed in the past. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat PSG or PSG with CPAP titration may be 
indicated in the circumstances listed in the Medicare rules section of this letter. 
 
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 split night sleep study. Our reviewer 
says that the request is medically reasonable and necessary. Our physician reviewer found the patient has OSA 
and change in clinical examination and symptoms, therefore, a split night sleep study is indicated for titration 
of therapy. Our reviewer also found that the patient requires a split night sleep study. 
 
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 split night sleep study have been met. Therefore, we decided that the Plan has 
to pre-approve a split night sleep study (95811).  
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraorifice barrier (D3911), an unspecified 
periodontal procedure (D4999 x4) and oral hygiene instructions (D1330). 
 
You asked the Plan to pre-approve the dental services. You say that you are supposed to have surgery in 
February, but the surgeon won't clear you until your dental work is done. The Plan denied your request. The 
Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
intraorifice barrier (D3911), an unspecified periodontal procedure (D4999 x4) and oral hygiene instructions 
(D1330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve oxygen concentrator. You say that this is medically necessary. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the needed equipment can 
be obtained 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 
an oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) and a segmental pneumatic appliance 
for use with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and garments. You say that you have 
attached the medical records documenting the lymphedema diagnosis and unique characteristics which 
preclude the use of a basic PCD for the treatment of multiple sclerosis. The Plan denied your request. The Plan 
says the records show that this device is being requested for chronic venous insufficiency which is not covered 
by Medicare guidelines. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
garments. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has lymphedema related to venous insufficiency of the lower extremities having failed conservative 
treatment or use of a basic pump. This is a request for a special pump (E0652). However, the provided 
documentation did not show improvement with compression device use in the right leg to justify use in both 
legs. Also, the enrollee did not have a required indication for use of this pump device as only venous 
insufficiency was listed and without mention of truncal edema. Therefore, the enrollee does not meet criteria 
for the device (E0652) and supplies which will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compression device and garments have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) and a segmental pneumatic appliance 
for use with pneumatic compressor, trunk (E0656).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Udenyca injection (Q5111). 
 You asked the Plan to pre-approve a medication. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says there is no record from the prescriber 
that shows the enrollee has tried one of the preferred drugs Fulphila or Neulasta. 
 
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 a medication. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
pancreatic cancer and is receiving myelosuppressive anti-cancer therapy. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Udenyca injection (Q5111).
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF.  
 
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. 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 the 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylpred. 
 
You asked the Plan to pre-approve the medication. You say that you want to appeal this denial. 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 Methylpred.
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 are requesting seven to fourteen days. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee requires treatment by multiple therapies, including physical and occupational therapy, and could 
tolerate the therapy in the IRF, the complexity of their condition doesnt require an IRF stay and care can be 
provided in a lower level.  
 
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 continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. Although this enrollee's A1c is 1.2, the enrollee is not prescribed 
insulin nor medications that typically cause low blood sugars. We are also not told that the enrollee is having 
low blood sugars. Although a CGM may help this enrollee, the coverage criteria for a CGM are not met. We 
are also not told why the fingerstick meter would not suffice for this enrollee. If the enrollee is started on 
insulin, the records should be submitted and the case re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 enrollee needs IRF services to regain his 
independence. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an 
IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation (HGNS) (64582, C1767, 
C1778, C1787). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically 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 services. Our physician reviewer 
found a hypoglossal nerve stimulator (Inspire device) is not medically necessary because Medicare criteria are 
not met. This enrollee has moderate obstructive sleep apnea and is intolerant of CPAP. The enrollee meets all 
criteria for the Inspire device except the body mass index is 36.25, as of October 24, 2023. Medicare requires 
the BMI to be less than 35. The denial is upheld. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hypoglossal nerve stimulation (HGNS) (64582, C1767, C1778, C1787).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service July 28, 2023. 
 
You asked the Plan to pay for code 99223. You say that the diagnosis code billed is valid and payable. The 
Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I21.A1. This code 
is not an appropriate primary diagnosis as he code has a code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for code 99223 billed for date of service 
July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Mis reader. 
 
You asked the Plan to pre-approve the FreeStyle Mis reader. You say that the medical records provided support 
the need for the requested CGM.  The Plan denied your request. The Plan says a CGM is covered under 
Medicare only if a member with diabetes is on insulin or has documentation of very low blood sugars that has 
occurred several times.  
 
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 Mis reader. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by Medicare rules. 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 the FreeStyle Mis reader have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Mis reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on July 7, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that the provided CGM was medically 
necessary.  The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided 
CGM.  
 
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 pay for procedure code A4239. Our reviewer says 
that the enrollee did not meet criteria for the provided CGM.  Our physician reviewer found coverage criteria 
for a CGM require insulin use or low blood glucose. This enrollee in 2022 is on metformin alone which should 
not cause low blood glucose. We are not told of low blood glucose. Although a CGM may help this enrollee, 
criteria for coverage are not met. We are also not told why a fingerstick meter would not suffice for this 
enrollee 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 procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 provided on July 7, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee was on oral bisphosphonates for 8 years 
which was ineffective. You say that the enrollee had a left hip and scrum fracture after a fall in June 2023. You 
say that the enrollee needs to resume treatment. You also say that Prolia is planned. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs, pamidronate or zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred drugs. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the Plan's preferred drugs. Therefore, the reviewer 
found that the step therapy criteria for Prolia have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).