Persius/hicric huggingface dataset:
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 
due to disc bulging in their spine. The Plan denied your request. The Plan says the requested procedure 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 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 endplate 
changes without facet 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonadjunctive, nonimplanted continuous glucose 
monitor (CGM) (E2103) and supply allowance (A4239). 
 
You asked the Plan to pre-approve a non-adjunctive CGM and supplies. You say that the enrollee has a 
diagnosis of severe non-proliferative diabetic retinopathy and cataracts in both eyes. The CGM is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee does not have hypoglycemia and is not taking insulin. 
 
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 a non-adjunctive CGM and supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nonadjunctive, nonimplanted continuous glucose monitor (CGM) (E2103) and 
supply allowance (A4239).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as there has been two 
medial branch blocks at each side with 80% relief. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is covered when there 
has been dual medial branch blocks with 80% relief of pain. 
 
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 reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee had medial branch blocks which provided at least 80% relief of primary 
(index) pain. The review has determined that the enrollee meets the coverage criteria. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve radiofrequency ablation.  
 
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 transfer bench (E0248). 
 
You asked the Plan to pre-approve a transfer bench. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a transfer bench is not covered because it is not 
primarily medical in nature.  
 
While a transfer bench 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 transfer bench (E0248).
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 the services are medically necessary for 
the enrollee's complex medical needs to ensure a safe discharge. The Plan denied your request. The Plan says 
the enrollee's medical needs are being met in the current setting. 
 
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 enrollee appears to be improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at 
the current facility.  
 
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: 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 the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee can safely 
receive their care in the hospital setting. 
 
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 enrollee is currently receiving all indicated care in the acute care hospital. There 
are no specific treatments that the enrollee would receive at the LTACH that are not currently covered. It is not 
clear they require LTACH level of care on discharge. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 18, 2023, billed with 
procedure codes 96365-59 and 96366-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This service is a non-covered service and is 
not payable. Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 
18, 2023, billed with procedure codes 96365-59 and 96366-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are ready and able to participate in the IRF level 
of therapy required to regain independence. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture testing provided on May 4, 2023, billed 
with code 87086. 
 
You asked the Plan to pay for the urine culture. You say that this testing is medically necessary and should be 
paid.  The Plan denied your request. The Plan says the test at issue was not ordered by the treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic testing must be ordered by a treating 
physician.  
 
We looked at the file and Medicare rules. Review of the order shows that a urinalysis was ordered but no 
specific order was included for a urine culture. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Therefore, we decided that the Plan does not have to pay for 
the urine culture testing provided on May 4, 2023, billed with code 87086.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) will be denied as 
noncovered, since it does not meet the definition of a prosthesis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to pre-
approve a mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automated blood pressure device (A4670). 
 You asked the Plan to pre-approve the blood pressure device. You say that you are legally blind, and you need 
the talking blood pressure monitor. The Plan denied your request. The Plan says the requested item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve the automated blood pressure device 
(A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM sensor. You say that your family doctor, heart surgeon 
specialist, and general doctor all recommended to put in this special order for a Dexcom G7 to be approved 
because it is needed to maintain your health and keep you out of the hospital. The Plan denied your request. 
The Plan says there has not been sufficient evidence to justify payment for a non-covered device. 
 
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. Medicare 
rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the 
preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure 
that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The 
rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
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 Dexcom G7 CGM sensor. Our 
physician reviewer found the coverage criteria for a CGM requires the use of insulin or low blood glucoses 
(BGs). The medications you are on do not cause low BGs and we are not told of low BGs hence, criteria for 
CGM coverage are not met. 
 
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 Dexcom G7 CGM sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (G0482) provided on November 16, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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, the CPT Code Manual definition of code G0482 is drug testing, definitive, 15-21 drug class(es). 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the physician order 
provided does not specify what drug classes are being tested for. Based on this information, we decided that 
Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (G0482) provided on November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not stable to return home requiring 
aggressive rehabilitation. The Plan denied your request. The Plan says your records do not show that your 
rehab needs are complex. The Plan says that the services needed may be provided safely in a lower level of 
care.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
rehabilitation stay versus a lower level of care, as rehabilitation goals include returning to prior level of 
function as independent. The Plan denied your request. The Plan says the enrollee's records do not show 
rehabilitation needs are complex. The Plan says that the services needed may be provided safely in a lower 
level of care.  
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 19, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the billed testing be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen treatment (99183 x30 and G0277 
x150) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve hyperbaric oxygen treatment to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria 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 
hyperbaric oxygen treatment (99183 x30 and G0277 x150) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 1, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on August 5, 2021.