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 the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do not meet the clinical 
requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin or has a history of problematic hypoglycemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs/medicaments dispensed in the office (D9630), 
localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), and a core build-up (D2950) 
provided on May 23, 2023. 
 
You asked the Plan to pay for D9630, D4381, D4921, and D2950. You say that you do not feel like you should 
have to pay because you were not satisfied with the work done. The Plan denied your request. The Plan says 
these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
drugs/medicaments dispensed in the office (D9630), localized delivery of antimicrobial agents (D4381), 
gingival irrigation (D4921), and a core build-up (D2950) provided on May 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard DNA test.  
 
You asked the Plan to pre-approve Cologuard DNA test. You say that the Cologuard DNA test is medically 
necessary.  The Plan denied your request. The Plan says the requested Cologuard DNA test does not meet the 
Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the Cologuard DNA test is covered when the criteria 
listed in the Medicare rules section of this decision are met. 
 
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 Cologuard DNA test. Our reviewer says 
that the requested Cologuard DNA test is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that Medicare coverage criteria does not recommend patients older than 85 years old 
to use this test for screening. Therefore, you do not meet the criteria for the Cologuard DNA test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cologuard DNA test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Cologuard DNA test.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for radiation therapy. We decided that the Plan does not 
have to reduce the coinsurance for Medicare Part B chemotherapy drugs.  
 
You asked the Plan to reduce the cost share for Medicare Part B chemotherapy drugs and radiation therapy 
provided from February 27, 2023, to March 1, 2023. You say that the facility obtained a pre-approval and 
advised you the cost share would be $110. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost share for radiation therapy.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). Your contract with the Plan states you must pay 20% 
coinsurance for radiation therapy; However, the Plan charged a $110 copayment for this service. Therefore, we 
decided that the Plan has to reduce the cost share to $60.71 coinsurance, which is 20% of the allowed amount 
for radiation therapy provided on March 1, 2023 ($303.54 allowed x 20% = $60.71). 
 
We also decided that the Plan does not have to reduce the coinsurance for Medicare Part B 
chemotherapy drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B chemotherapy drugs. You have been asked to pay $961.82 coinsurance, which 
is 20% of the total allowed amount for Medicare Part B chemotherapy drugs provided from February 27, 2023, 
to March 1, 2023 ($4,809.11 total allowed x 20% = $961.82). Therefore, we decided that the Plan does not 
have to reduce the cost share for Medicare Part B chemotherapy drugs. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 3D technique and daily image-guided radiation therapy (IGRT) 
(77014, 77387 x16). 
 
You asked the Plan to pre-approve 3D technique and daily IGRT. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 3D technique and daily IGRT. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found daily IGRT using either daily kilovoltage/kilovoltage (KV/KV) or daily port 
films is strongly recommended to ensure the safety and accuracy of radiation delivery for 16 fractions. Weekly 
IGRT and daily IGRT as needed is medically necessary for radiation treatment in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D technique and daily IGRT have been met. Therefore, we decided that the 
Plan has to pre-approve 3D technique and daily image-guided radiation therapy (IGRT) (77014, 77387 x16).  
 
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 stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that this item would be very useful for you because 
you have difficulty with stairs. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 You asked the Plan to pre-approve the drug. You say that you need the injection for your legs. You say that you 
are in pain and the previous injections did not work.  The Plan denied your request. The Plan says that the step 
therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that that 
Durolane is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Monovisc, Orthovisc, Synvisc or Synvisc One. Also, there is no indication that the Plan's 
required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on March 22, 2023, 
to March 25, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee met the criteria guidelines for the diagnosis. The Plan denied your request. The Plan says the diagnosis 
code is not validated in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee presented to the hospital with altered 
mental status and hypoglycemia. She was reported as being somnolent, but without acute distress. She was 
given dextrose fluids (D50) which led to her mental status returning to baseline. Workup and evaluation 
following fluids included no hypotension, no hypoxia, normal platelets, normal bilirubin, normal creatinine, 
and no oliguria. Sepsis-3 criteria was not met as there was insufficient evidence of organ failure directly related 
to a dysregulated response to systemic infection. The enrollee was dehydrated with hypoglycemia and 
responded to D50 fluids. Therefore, the diagnosis code, A41.9 (sepsis) is not supported for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on March 22, 2023, to March 25, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
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 the LTACH services. You say that an LTACH admission would vastly 
improve the enrollee's opportunity and potential to return to their baseline status, while also minimizing the 
enrollee's risk of falling and declining at a lower level of care. You say that the enrollee continues to suffer 
ongoing medical complications and needs close physician monitoring which cannot be managed at a lower 
level of care.  The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve the orthotic device. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says there are not enough studies to show MyoPro is safe and effective 
to help the enrollee recover from their 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 the orthotic device. Our reviewer says 
that the requested MyoPro orthotic device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes 
for the enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. Therefore, the reviewer found that the requested MyoPro orthotic device is not medically 
reasonable or 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 orthotic device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro powered arm brace.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure has not been shown to be a safe or helpful treatment 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says this procedure is considered 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint disease or stenosis. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 8 units of procedure code 87150 billed for date of service 
May 24, 2023. 
 
You asked the Plan to pay for procedure code 87150. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 87150 is a column II code to column I code 87500; however, 87150 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87150. Our reviewer says that procedure 
code 87150-XU is not supported. Our reviewer found the record does not support that a separately identifiable 
organism culture was tested via amplified probe technique. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for 8 units of procedure code 87150 billed for date of service May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), mandibular partial 
denture (D5214), core buildup (D2950), pontics (D6245 x 3) and retainer crown (D6740). 
 
  You asked the Plan to pre-approve the dental services. You say that you have lost the ability to chew and 
require these procedures. Your teeth have roots that have grown around you jaw and to extraction them for 
complete dentures would result in extensive surgery. The Plan denied your request. The Plan says these 
services are either not covered benefits or 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 D6245 and D6740 was exhausted on authorization 202311173562632. Additionally, 
D5213, D5214 and D2950 are not covered under any circumstance. Therefore, we decided that the Plan does 
not have to pre-approve a maxillary partial denture (D5213), mandibular partial denture (D5214), core buildup 
(D2950), pontics (D6245 x 3) and retainer crown (D6740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), and a harness (E2313). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, and a harness. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has 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, expandable 
controller, and a harness. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found provided records document that the 
enrollee has 4-/5 bilateral upper extremity strength with active range of motion rated as within functional 
limits, thus indicating he has adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches. 
 
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, expandable controller, and a harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), expandable controller (E2377), 
and a harness (E2313).