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

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 22, 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 the LTACH services. You say that the enrollee would benefit from a 
regimented mobility schedule that cannot be facilitated in the current setting or at a lower level of care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and is currently 
unstable for 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 necessary, reasonable, and appropriate in this case. 
Our physician reviewer found the enrollee is not yet ready for a transfer to another care setting. No therapeutic 
advantage is anticipated with an LTACH transfer.  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: Favorable

 
We decided that the Plan has to pre-approve a nonadjunctive, nonimplanted continuous glucose monitor 
(CGM) and sensors (E2103, A4239). 
 
You asked the Plan to pre-approve a nonadjunctive CGM and sensors. You say that the requested CGM is 
needed for the enrollee. The Plan denied your request. The Plan says that the documentation fails to indicate 
that the enrollee is on insulin or has hypoglycemic events. 
 
The Plan must follow 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 a nonadjunctive CGM and sensors. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee does not have 
use of his left upper extremity; it will likely be hard for him to monitor his blood glucose with a finger stick 
glucometer for this reason. In addition, he was treated with insulin in September and in all likelihood, will need 
to be on insulin as soon as his a1c was 10.1 %. For these reasons, a CGM would be reasonable to use and 
covered. 
 
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 nonadjunctive CGM and sensors have been met. Therefore, we decided that 
the Plan has to pre-approve a nonadjunctive, nonimplanted continuous glucose monitor (CGM) and sensors 
(E2103, A4239).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a Sprint peripheral nerve stimulator. 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 a Sprint peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records show that the enrollee has bilateral knee pain, and the 
Sprint PNS device is experimental for knee 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 Sprint peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for teeth #6, 7, 8, 9, 10, 11 (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 pre-approve a 
crown for teeth #6, 7, 8, 9, 10, 11 (D7210).
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 the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says admission to an LTACH 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 appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. 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 advantageous at this time.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fentanyl patch. 
 
You asked the Plan to pre-approve a Fentanyl patch. You say that the enrollee has been on this medication 
since 2018 and has no problem paying for it. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Fentanyl patch.
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 the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee does not show a need for continued treatments and care in 
an LTACH 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 admission is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at an LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, the admission 
to an LTACH is not medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve routine transportation. You say that it is very important for the enrollee to 
make trips to this facility. The Plan denied your request. The Plan says routine transportation beyond 50 miles 
of driving distance per one-way trip is not covered by the Plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. The requested destination is more than 50 
miles driving distance per one-way trip. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation mileage.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
testing. 
 
You asked the Plan to pre-approve SPECT testing. You say that this is a precautionary measure that your 
doctor feels is necessary for your well-being. The Plan denied your request. The Plan says you do not meet 
criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that cardiovascular nuclear medicine may be covered for 
certain indications. 
 
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 SPECT testing. Our reviewer says that 
you do not meet criteria for this test. Our physician reviewer found you report occasional dyspnea with no 
exercise intolerance and no chest pains. Your cardiac examination is normal as is the electrocardiogram (ECG). 
There is no evidence provided that would support the need for radionuclide stress testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single photon emission computed tomography (SPECT) testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from May 1, 2023, to May 30, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the continued SNF care should be covered 
under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for 
continued SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the continue SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee did not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continue SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued skilled nursing facility (SNF) care provided from May 1, 2023, to May 
30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve. You say that 
this is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and 
investigational and 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 destruction by neurolytic agent, 
paravertebral facet joint nerve. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental 
because of the wide variation in efficacy of the procedure as reviewed in the literature.   
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, paravertebral facet joint nerve have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 5, 2022, 
to October 3, 2022.  
 
You asked the Plan to pay for home health services. You say that the services rendered to the enrollee were 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that a valid physician 
order and plan of care are not identified.  As such, the provided services are not coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from September 5, 2022, to October 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular repair (34705) and associated 
hospitalization. 
 
You asked the Plan to pre-approve endovascular repair and associated hospitalization. You say that this is 
medically necessary. The Plan denied your request. The Plan says the documentation does not show that the 
enrollee has a concomitant common iliac artery aneurysm with diameter of 3.5 centimeters or larger. 
 
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 endovascular repair and associated 
hospitalization. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not support the medical 
necessity of the procedure in question due to a lack of clarity. Most importantly, there is no medical record 
documentation articulating the nature of the problem and rationale for repair. There are numerous 
inconsistencies throughout the medical record regarding what condition the prior repair was designed to treat 
and the nature of the previous surgery. There is no clarity as to what is being repaired by the current request. It 
is unclear if the fluid collection represents an infection or is merely a previous (treated) iliac aneurysm 
sac. Nothing in the record suggests active extravasation or a non-thrombosed pseudoaneurysm and the most 
recent computed tomography scan is from late August. Recommend resubmitting with a cohesive narrative 
regarding the nature of the problem and rationale for 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 endovascular repair and associated hospitalization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endovascular repair (34705) and associated 
hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee's previous injection 
on September 26, 2022, produced 100 % pain relief for seven months. You say that the enrollee has had a 
gradual increase in their pain and now wishes to proceed with another radiofrequency ablation. The Plan denied 
your request. The Plan says the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the request is considered an experimental therapy because of the wide variation inefficacy reported in the 
literature. Therefore, the request is 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 the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vasopneumatic compression unit (VCU) and related 
accessories (E0673, E0666, 97760) provided on February 26, 2023, through March 27, 2023. 
 
You asked the Plan to pay for the VCU and related accessories. You say that the items were needed for post-
operative DVT prophylaxis. The Plan denied your request. The Plan says pneumatic compression devices are 
not covered by Medicare for the prevention of deep vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for a vasopneumatic compression unit (VCU) and related accessories (E0673, E0666, 97760) provided on February 26, 2023, through March 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service 
April 12, 2023. 
 
You asked the Plan to pay for procedure codes 87502 and 87798. You say that these services were necessary 
and were billed appropriately. The Plan denied your request. The Plan says these codes are not supported as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 codes 87502 and 87798. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the services reported with code 87502 
does not include testing for COVID-19. There is also no documentation of 7 probes for code 87798. 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 codes 87502 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service April 12, 
2023.