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

 
We decided that the Plan does not have to pre-approve consultation, treatment and multiple procedures 
including angioplasty, atherectomy, and/or stents (37220, 37221, 37224, 37226, 37227, 37228, 37229, 37230, 
37231, 37232, 37233, 37234, 37235). 
 
You asked the Plan to pre-approve outpatient procedures. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the notes show you are having pain in your legs 
when walking. You had an arterial duplex test done. The test does not show that you have blood flow issues in 
your legs. You do not meet criteria for approval of the requested tests and treatment. 
 
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 outpatient procedures. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not meet coverage criteria and does not support the medical 
necessity of the procedures in question. There appears to be a disconnect with respect to the physical 
examination/non-invasive testing results and the assessment and plan. The enrollee's symptoms are not 
consistent with ischemic rest pain. There is documentation of palpable pulses, and both the arterial blood flow 
and arterial duplex examinations are consistent with normal arterial perfusion to the lower extremities 
bilaterally. As there is no indication for intervention and the physical examination and non-invasive studies are 
consistent with normal lower extremity arterial perfusion, criteria are not met and unable to overturn the health 
plans determination on the basis of medical necessity. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve consultation, treatment and multiple procedures including angioplasty, 
atherectomy, and/or stents (37220, 37221, 37224, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 
37234, 37235).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve arthrodesis. You say that the procedure is medically necessary for the 
enrollee. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered by Medicare. Medically necessary services are services needed to diagnose or treat a medical condition 
and that meet accepted standards of medical practice. Therefore, it not considered standard of care. 
 
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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show there is no instability demonstrated on imaging. Also, the Minuteman device 
is experimental/investigational and there are not enough studies on a Minuteman procedure to show it is safe 
and/or effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abdominal binders (A4467). 
 
You asked the Plan to pre-approve the abdominal binders. You say that you are appealing the denial for an 
abdominal binder. These belts are needed permanently, not temporarily. The Plan denied your request. The 
Plan says the requested item is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the abdominal binders have not been met. Therefore, we decided that the Plan does not have to pre-
approve the abdominal binders (A4467).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says cardiac catheterization is medically needed if the enrollee has a high 
suspicion of coronary artery disease or if the enrollee is about to undergo high risk surgical procedures. The 
enrollee does not have a history of coronary artery disease, has not had a positive stress test, and is not going to 
have high risk surgery. Therefore, the denial is correct. There are other tests that the enrollee can have to 
evaluate her heart arteries that are safer. 
 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 left heart catheterization. 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 a history of chest pains. The enrollee previously had a 
stress test for this problem in 2019. There is no evidence of an uninterpretable ECG. The medical records 
provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollee's 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. You asked the Plan to pre-approve a Freestyle Libre 2. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been 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 a Freestyle Libre 2. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that low blood glucose levels would 
not be expected with just metformin and Ozempic but may occur with glipizide. There is no documentation of 
low blood glucose levels or insulin use nor of any reason why fingerstick meter monitoring would not be 
sufficient. 
 
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 Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial due to 
medical necessity. The Plan denied your request. The Plan says the left heart catheterization 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 left heart catheterization. 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 a history of chest pains. The physician requests 
authorization for cardiac catheterization. The enrollee's recent radionuclide stress test showed no imaging 
evidence of ischemia. The medical records provided do not support the rationale for this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time 
cardiac catheterization would not be considered medically appropriate and necessary in this enrollee's 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on February 20, 2023. 
 
You asked the Plan to pay for the x-ray. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 10, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the x-ray provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable socket described by code L5999. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested code is not covered. 
 
The Plan must follow Medicare rules. The rules say that Code L5999 must not be used to bill for any features 
or functions included in the socket or addition codes. 
 
We looked at the file and Medicare rules. The file shows that the socket is being requested with code L5999. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an adjustable socket described by code 
L5999.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee no 
longer had skilled nursing facility needs.   
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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97110, 97112, 97530) provided from 
January 2, 2023, to January 17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for therapeutic services. You say that the provider was in the process of becoming 
in-network on these dates of service. The Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for therapeutic services (97110, 97112, 97530) 
provided from January 2, 2023, to January 17, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS HF system (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS HF system. You say that the device is medically necessary. 
The Plan denied your request. The Plan says this device has not been shown to improve outcomes with your 
heart problem. It is still considered experimental. Services that are experimental or investigational 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 CardioMEMS HF system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollee's 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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CardioMEMS HF system (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0668, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that coverage of 
an E0652 is allowed when an individual has unique characteristics that prevent them from receiving 
satisfactory pneumatic compression treatment from an E0650 or E0651. The Plan denied your request. The 
Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed 
four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0668, E0656).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the implantation of an intrathecal pain pump. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee does have an implanted spinal cord 
simulator which does provide some relief for their longstanding chronic intractable pain.  The Plan denied your 
request. The Plan says that implantation of an intrathecal pain pump is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that 
the requested procedure is medically necessary. Our physician reviewer found that there are several articles 
which support dual modality therapy. There are also no reports of cross talk between an intrathecal (IT) pump 
and a spinal cord stimulator (SCS) implant. Therefore, the request is 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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve the implantation of an intrathecal pain pump.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iovera cryoneuroablation. 
 
You asked the Plan to pre-approve Iovera cryoneuroablation. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is 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 Iovera cryoneuroablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental therapy 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 Iovera cryoneuroablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Iovera cryoneuroablation.