Persius/hicric huggingface dataset:
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 CGM. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that pain has only continued to 
get worse and there are days when it is very difficult to walk or stand for very long. You say that the pain 
radiates across your hips and down both legs to the ankles and taking Tramadol, Tizanidine, and Gabapentin 
keeps you groggy all day. The Plan denied your request. The Plan says review of the current medical literature 
does not consider this service to be standard medical treatment for your condition. Additionally, records do not 
indicate that you have knee pain, or that your doctor is planning to perform this ablation treatment to your 
knees. 
 
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 genicular radiofrequency ablation. Our reviewer says that the requested genicular radiofrequency ablation is not considered medically reasonable and 
necessary. Our physician reviewer found that the notes refer to radiofrequency ablation of the medial branches 
and not the genicular nerves. There is no discussion of genicular nerve blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The requested service cannot be 
recommended as the elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) brain imaging. 
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records indicate that the enrollee has 
progressive cognitive changes in memory and language.  The record indicates that the initial work-up has not 
been completed. The record provided does not establish that the enrollee meets the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia or that the examination is being requested in the context of a 
clinical trial. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) brain imaging.
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 CGM. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not use insulin or have a documented history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have 
documented problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on June 28, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that the doctor didn't do anything else 
outside of the wellness visit. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to doctor and other health care 
provider services.  
 
The item or service you asked the Plan to waive the deductible for falls within the doctor and other health care 
provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $800 deductible which applies to doctor and other health care provider services. This cost sharing 
is a contractual obligation that had not been met at the time the office visit was received on June 28, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit on June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography. 
 
You asked the Plan to pre-approve a PET scan.. You say that the enrollee is favorable for immediate risk of 
prostate cancer and favors definitive management. The Plan denied your request. The Plan says advanced 
imaging is not routinely indicated for the initial staging of favorable intermediate risk prostate cancer; the 
request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of favorable intermediate risk prostate cancer and has not received treatment.  The noted clinical 
scenario is not one for which coverage is available under the rules. The elements of the coverage criteria are not 
satisfied.  The requested service is not 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 PET scan. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that the requested procedure is 
medically necessary to treat the enrollee's pain. The Plan denied your request. The Plan says the requested 
procedure does not meet the requirements for approval. 
 
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 facet joint radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the request exceeds the utilization limit of two sessions in a rolling 12-
month period. Therefore, the request is considered not 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 facet joint radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a facet joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services (90945) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve dialysis services. You say that the requested provider is a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for coverage for OON services 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 
dialysis services (90945) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 22846 billed for date of service July 12, 
2023. 
 
You asked the Plan to pay for procedure code 22846. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 22846 is bundled into 
payment for code 22853. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 22846 
is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 22846 billed for date of service July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complex repair (13101 and 13102) provided on May 17, 
2023. 
  
You asked the Plan to pay for the complex repair (13101 and 13102). You say that the services were medically 
necessary, and the claim should be reprocessed accordingly. The Plan denied your request. The Plan says an 
assistant surgeon cannot be paid. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13101 and 13102. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the complex repair (13101 and 13102) have not been met. Therefore, we decided that the Plan does 
not have to pay for the complex repair (13101 and 13102) provided on May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection (64494) at level L5-S1. 
 
You asked the Plan to pre-approve a facet joint injection at level L5-S1. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria listed 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 facet joint injection at level L5-S1. 
Our reviewer says that the requested facet joint injection is not medically necessary. Our physician reviewer 
found the records do not show physical exam evidence that the facet joints at L5-S1 are the cause of pain. The 
is no evidence that the L5-S1 level is symptomatic and causing back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facet joint injection at level L5-S1 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a facet joint injection (64494) at level L5-S1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor, center mount foot platform and bracket. 
 
You asked the Plan to pre-approve an electronic connection, center mount foot platform and bracket. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria 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 an electronic connection, center mount 
foot platform and bracket. 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 adequate strength to 
manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, center mount foot platform and bracket have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and one power seating system motor, center mount foot platform and bracket.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that they are under the impression that the drug is being 
provided by the pharmacy, but the injection is being done in the provider's office. The Plan denied your 
request. The Plan says Orthovisc will be supplied by a pharmacy. The Plan says for this reason, your request is 
denied under your medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc (J7324).  
 
Benefits for Orthovisc 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan of the head or brain and the CT scan of the face 
provided on June 22, 2023. 
 
You asked the Plan to pay for the CT scan of the head or brain and the CT scan of the face. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says Original Medicare 
is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the CT scan of the head or brain and the CT scan of the face 
provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on August 1, 2023. 
 
You asked the Plan to pay for an extraction. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
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 pay for an extraction (D7140) provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says epidural steroid 
injections is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injections have been met. 
Specifically, without medical records we cannot determine if the epidural steroid injections were medically 
necessary. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an OON consultation. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not covered from an OON provider. 
 
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 consultation to be provided by an out-of-network (OON) provider.