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

 
We decided that the Plan does not have to pre-approve a tendon sheath injection to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a tendon sheath injection to be provided by the requested out-of-network 
provider. You say that you have been seeing this provider for treatment. The Plan denied your request. The 
Plan says according to the clinical documentation, the medically necessary services are available in the service 
area with participating providers and there is no documentation for a six (6) month supervised conservative 
exercise routine nor the patient is using properly fitted over-the-counter orthotics.  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 Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The requested provider in this case is not a network provider with the Plan. The records show that the service at 
issue is not manual manipulation of the spine. The Plan has network providers available who can provide the 
services at issue in this appeal. We found no exception that would require the Plan to pre-approve these 
services. Therefore, we decided that the Plan does not have to pre-approve a tendon sheath injection to be 
provided by the requested out-of-network provider.
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 the services are needed due to your medical 
conditions. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 
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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that you need this Freestyle Libre 3. The Plan 
denied your request. The Plan says this is not a covered continuous glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device had not been reviewed by the PDAC prior to June 15, 2023. As such, this non-adjunctive 
CGM device is not eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 3.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close medical oversight that can 
only be offered in an acute rehabilitation unit. The Plan denied your request. The Plan says that a medical need 
for an acute rehabilitation facility admission has not been shown at this time.  
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. Indeed, the enrollee's condition is in fact complex and fragile, and there is every reason to expect 
that they will participate in and benefit from services provided at the 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466x3). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show that the ordered settings for the noninvasive ventilator show it is going to be used only in a bi-
level pressure mode. 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have documented COPD and 
chronic respiratory failure. You do not meet requirements for home ventilation as documentation does not 
support BIPAP failure. Also, BIPAP can be used with average volume assured pressure support (AVAPS) 
mode, which has been prescribed.  Hence, does not require home ventilator at this time, per documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466x3).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty (22514). 
 You asked the Plan to pre-approve the services. You say that the enrollee has a subacute fracture that has not 
healed after 12 weeks due to osteoporosis. You say that the enrollee has debilitating pain and this procedure 
will alleviate the pain.  The Plan denied your request. The Plan says the request is not medically necessary 
because the enrollee does not have an acute or subacute fracture.  
 
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 detailed documentation is not evident regarding an acute/subacute fracture at the L1 level. The noted 
compression fracture has been reportedly present since at least December 2022. There is no indication of a 
progression of the body height loss, greater than 25 percent vertebral body height loss, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other 
plausible causes of pain. Therefore, you do not meet the LCD criteria for coverage. 
 
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 a kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on October 17, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that this provider is enrolled under the patient's 
benefit plan and the services are necessary for the patient. The Plan denied your request. The Plan says virtual 
care is not covered out-of-network. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) are not covered out-of-network. Based on this information, we decided 
that Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan 
does not have to pay for telehealth services provided on October 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on April 24, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on April 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the patient has a mild headache. She had a 
negative CT of the brain on July 3, 2023, and has no neurological deficit nor is she on anticoagulants. The 
negative CT is not referenced in the last encounter and there is no rationale why a repeat CT brain is necessary 
since there has been no neurological change. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the head or brain.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 1, 
2023, to March 2, 2023. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 pay for 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 the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services 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 pay for skilled nursing facility (SNF) care provided from February 1, 2023, to March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a tooth extraction (D7210), and intraoral imaging 
(D0220) provided May 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the amount you are 
being asked to pay. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a tooth extraction (D7210), and intraoral 
imaging (D0220) provided May 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that the 
member has a history of coronary artery bypass grafting in 2008, which is greater than 5 years ago. You say 
that the member also has not undergone an evaluation for CAD since 2018, which is greater than 2 years ago. 
You say the member will be exercising on the treadmill for this test. The Plan denied your request. The Plan 
says myocardial perfusion imaging, tomographic (SPECT) does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that myocardial perfusion imaging, tomographic (SPECT) is not 
considered medically necessary in this case. Our physician reviewer found that the enrollee has no cardiac sign 
or symptoms. There is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or 
that the enrollee is unable to exercise. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this enrollees clinical management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychotherapy services. 
 
You asked the Plan to pre-approve the psychotherapy services. You say that the enrollee has post-traumatic 
stress disorder (PTSD) and has known improvement in symptoms when enrolled in the appropriate therapies. 
You say that you recommend she pursue and continue treatment with this mental health counselor for PTSD. 
The Plan denied your request. The Plan says the Plan criteria and the 2023 Evidence of Coverage states that a 
Licensed Professional Counselor (LPC) is an ineligible mental health provider. Additionally, the Medicare 
Program Integrity Manual also lists an LPC as an ineligible mental health provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Precision Q-I-D test strips 100/33. 
 
You asked the Plan to pre-approve Precision Q-I-D test strips 100/33. You say that that enrollees diagnosis is 
Type 2 Diabetes Mellitus with Hyperglycemia. You also say that the enrollee is stable on current medication 
with no adverse effect, and their testing frequency is as needed. The Plan denied your request. The Plan says 
you have not provided medical reasons why the preferred test strips would not meet the enrollee's medical 
needs. The Plan also says they attempted to contact you (the enrollee's provider) to conduct a peer-to-peer 
review, but were unsuccessful.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage organizations may limit 
coverage to certain Durable Medical Equipment (DME) brands, items, and supplies.  
  
We looked at the file and Medicare rules. The contract clearly states that the Plan requires the use of blood 
glucose monitors and test strips that are ACCU-CHEK manufactured by Roche, or Trividia products. 
 Therefore, we decided that the Plan does not have to pre-approve Precision Q-I-D test strips 100/33.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye exam (92004), a refraction (92015), 
office visits (99203, 99204, 99205) and procedures (76514, 92025, 92132, 92285, 92286) with an 
ophthalmologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and procedures. You say that you are requesting reconsideration 
because you are at risk of losing your eyesight. The Plan denied your request. The Plan says you must receive 
services from a network provider. There are in-network provider(s) within a reasonable distance from your 
location that can provide these services. 
 
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 
a medical eye exam (92004), a refraction (92015), office visits (99203, 99204, 99205) and procedures (76514, 
92025, 92132, 92285, 92286) with an ophthalmologist 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 CardioMEMS device and implantation (C2624, 
33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the requested device is not covered as it is 
investigational/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 CardioMEMS device. 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 Food and Drug Administration (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 congestive heart failure (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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device and implantation (C2624, 33289).