Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-implanted continuous glucose monitor (CGM), supply 
allowance and accessories  provided on July 5, 2023. 
 
You asked the Plan to pay for the CGM, supply allowance and accessories. You say that you have submitted 
proof of delivery along with other supporting documentation, but the claim keeps denying for missing this 
information. The Plan denied your request. The Plan says the provider is not a plan contract provider and is not 
enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a non-implanted continuous glucose 
monitor (CGM), supply allowance and accessories  provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) and the limited oral evaluation 
(D0140) provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had changed dentists and they found a 
second cavity that your previous dentist missed.  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 services were exhausted on date of service January 5, 2023. Therefore, we 
decided that the Plan does not have to pay for the periapical x-ray (D0220) and the limited oral evaluation 
(D0140) provided on September 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that the family has revoked the 
hospice care. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
   
The enrollee ended Medicare Hospice benefits on January 10, 2024. The services in question were requested 
before the end of that month. Therefore, we decided that the Plan does not have to pre-approve inpatient 
hospital admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SPRINT PNS. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT device is experimental for chronic pain treatment.  
 
   
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 SPRINT PNS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease services provided on August 31, 
2023. 
 
You asked the Plan to pay for end-stage renal disease services. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for end-stage renal disease 
services provided on August 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulmonary function test (PFT) provided on September 21, 
2023. 
 
You asked the Plan to pay for a pulmonary function test (PFT). You say that this was medically necessary and 
did not require a referral. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pulmonary function 
test (PFT) provided on September 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient behavioral health admission provided on May 
26, 2023, to May 29, 2023. 
 
You asked the Plan to pay for an inpatient behavioral health admission. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee has exhausted all 
benefit inpatient psychology days. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment may not be made for more than a 
total 190 days of inpatient psychiatric hospital services during the enrollees lifetime.  
 
We looked at the file and Medicare rules. According to Medicare, the enrollee had exhausted their lifetime 
inpatient psychiatric days as of January 27, 2023. Based on this information, we decided that Medicare rules 
for coverage of inpatient behavioral health admission have not been met. Therefore, we decided that the Plan 
does not have to pay for an inpatient behavioral health admission provided on May 26, 2023, to May 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is considered to be medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a ventilator. 
 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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for a ventilator. Our physician reviewer found the enrollee does not have 
supporting data or documentation to require a home ventilator. The enrollee has idiopathic pulmonary fibrosis 
(IPF) with chronic respiratory failure. The documentation does not support the medical necessity and rationale 
for a ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tepezza. 
 
You asked the Plan to pre-approve Tepezza. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the documentation does not show that the enrollee has had less than 8 
Tepezza infusions. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tepezza. Our reviewer says that the 
enrollee does not meet criteria for Tepezza. Our physician reviewer found Tepezza is Food & Drug 
Administration (FDA) approved for treatment of thyroid eye disease up to 8 infusions including initial dosage. 
The records do not show that the enrollee has not already received 8 infusions. Tepezza in excess of 8 infusions 
is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tepezza.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Durysta. 
 
You asked the Plan to pre-approve Durysta. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says Durysta should not be re-administered to an eye that received a prior dose 
of Durysta. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Durysta. Our reviewer says that the 
enrollee does not meet criteria for Durysta. Our physician reviewer found Durysta is not Food & Drug 
Administration (FDA) approved for the enrollee's condition. The requested use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Durysta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
experimental for knee pain treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management provided on September 25, 
2023. 
 
You asked the Plan to pay for evaluation and management. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for evaluation and 
management provided on September 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee has stabilized and is ready for 
discharge to the LTACH. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for an IRF admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving with the current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current treatment 
facility until more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as it would not be clinically advantages. Completion of treatment at the 
current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan, heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan, heart, without contrast material, with quantitative evaluation of 
coronary calcium. You say that this is medically necessary. The Plan denied your request. The Plan says you do 
not meet Plan guidelines for coverage. 
 
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 a CT scan, heart, without contrast 
material, with quantitative evaluation of coronary calcium. Our reviewer says that CT imaging of the heart 
without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of your medical condition. Our physician 
reviewer found there is insufficient support in the peer-reviewed literature demonstrating a significant benefit 
of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal 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 CT scan, heart, without contrast material, with quantitative evaluation of 
coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography (CT) scan, heart, without contrast material, with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73600 billed for date of service August 27, 
2023. 
 You asked the Plan to pay for procedure code 73600. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 73600 is bundled into payment for code 
73610. 
 
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 73600 
is a column II code to column I code 73610. 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 73600 billed for date of service August 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac (SI) joint, 
anesthetic/steroid, with image guidance including arthrography when performed (27096). 
 
You asked the Plan to pre-approve a SI joint injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records mention 10% relief which is not reasonable and 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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not clearly document SI joint dysfunction on examination and imaging 
does not show SI joint instability, or lesion. Also, previous injection result does not document more than 75% 
pain relief.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance 
including arthrography when performed (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SPRINT PNS. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT device is experimental for chronic pain treatment. 
 
   
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 SPRINT PNS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) (64555).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service July 8, 2023. 
 You asked the Plan to pay for procedure code 74176. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for code 
74178. 
 
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 74176 
is a column II code to column I code 74178. 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 74176 billed for date of service July 8, 2023.