Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D (brush) biopsy testing provided on August 23, 
2020. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that The American Society of Gastrointestinal Endoscopy suggests using WATS 3D (brush) biopsy 
testing in patients with known or suspected Barrett?s esophagus. The available clinical documentation in the 
case file does not support that the enrollee in this case has known or suspected Barrett?s esophagus. The 
documentation does not support that the WATS 3D biopsy testing was medically reasonable and necessary for 
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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the WATS 3D (brush) biopsy testing provided on August 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on August 10, 2020. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that you would like reconsideration because 
this is a covered Medicare benefit. The Plan denied your request. The Plan says the member does not meet 
Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being 
considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ConfirmMDx testing have not been met. Specifically, the record indicates that the member has 
a recent history of prostate cancer which is under active surveillance. Therefore, we decided that the Plan does 
not have to pay for ConfirmMDx testing (81551) provided on August 10, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at 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 above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip 
fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. 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 documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. 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. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like 
reconsideration because the member has swelling of their core. The Plan denied your request. The Plan says 
there is no documentation of edema extending onto the chest, trunk and/or abdomen 
 
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 pneumatic compression device. 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 that this member has specific findings 
of lymphedema of the chest, trunk, or abdomen. The member does not have unique characteristics that would 
indicate the segmented pump over a standard pump. There is no documentation of a four week trial and failure 
of the standard pump with detailed measurements. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 23, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the facility did not get authorization so you 
like the Plan to not penalize the doctor. The Plan denied your request. The Plan says you did not request prior 
authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the nursing facility care provided on April 23, 2020 by an out of network 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy re-evaluation. 
 
You asked the Plan to pre-approve the re-evaluation. You say that you would like reconsideration because one 
additional visit is required to re-evaluate the member's progress. The Plan denied your request. The Plan says 
the member does not meet medical necessity criteria for the requested visit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 re-evaluation. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided there is no documentation that 
the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or 
deliver a program to maintain the member's current condition or to prevent or slow further deterioration. 
 
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 re-evaluation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the physical therapy re-evaluation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on August 26, 2020. 
 
You asked the Plan to pay for the dental service. You say that this is your annual dental x-ray. You say that you 
believe that the periapical x-ray that you received is covered under your preventive dental care. The Plan 
denied your request. The Plan says the periapical x-ray is not listed as a covered service. The Plan also says 
that any services not listed are not covered. 
 
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 the 
periapical x-ray (D0220) provided on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like 
reconsideration because you have swelling as a result of surgeries. The Plan denied your request. The Plan says 
documentation does not show that you have severe and persistent chronic truncal, chest, or abdominal 
lymphedema. 
 
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 pneumatic compression device. 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 that you have lymphedema of the 
chest, trunk, or abdomen on treating medical provider progress notes. You do not have unique characteristics 
that would indicate the segmented pump over a standard pump. There is no documentation of a four week trial 
and failure of the standard pump with detailed pre and post measurements. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve IUD insertion received on December 16, 2019. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary due to health 
complications. The Plan denied your request. The Plan says that there is limited coverage if there is a history of 
uterine hyperplasia. 
 
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 the procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the levonorgestrel IUD is approved by the FDA for the treatment of heavy menstrual bleeding which also 
alleviates dysmenorrhea.  It is a safe, effective, and medically reasonable and accepted treatment for 
dysmenorrhea. The fact that it also provides contraception is not relevant. This is required for treatment of a 
medical condition and should be 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 the procedure have been met. Therefore, we decided that the Plan has to pre-
approve IUD insertion received on December 16, 2019.  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the co payment for radiologic examination, spine, lumbosacral 
(72110) provided. 
 
You asked the Plan to waive the co payment for the radiologic examination of your spine. You say that you 
should not be responsible to pay the co payment. The Plan denied your request. The Plan says the correct 
co payment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
co payment for outpatient diagnostic tests.  
 
You have been asked to pay a $50 co payment for the radiologic examination of your spine. The radiologic 
examination of your spine falls within the outpatient diagnostic tests benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the co payment for radiologic examination, spine, lumbosacral (72110) provided.
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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested 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 the enrollee was hospitalized on January 17, 2021, for the treatment of sepsis with 
altered mental status, low blood pressure and anemia. The infection was likely to have arisen due to an infected 
sacral pressure ulcer and bilateral foot ulcers (the left fifth toe with exposed bone from a prior amputation). The 
enrollee initially required blood transfusions, and intravenous medications to support the enrollee's blood 
pressure in addition to intravenous antibiotics. The enrollee's medical condition has stabilized. The sacral ulcer 
was surgically debrided but a tissue destroying infection (necrotizing fasciitis) was not found. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where the enrollee is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laparoscopy provided on August 27, 
2020. 
 
You asked the Plan to waive the copayment for a laparoscopy. You say that you disagree with the charges 
because you should owe an ambulatory copayment instead of an outpatient hospital copayment. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
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 a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and a $300 
copayment when provided at ambulatory surgical centers.  
 
The record shows that you received a laparoscopy on August 27, 2020, at an outpatient hospital facility. 
Therefore, you are responsible to pay the $350 copayment.  
 
You have been asked to pay a $350 copayment for a laparoscopy. A laparoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a laparoscopy provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial denture (D5820) provided on September 
25, 2020. 
 
You asked the Plan to pay for an interim partial denture. You say that you were told this would be covered. The 
Plan denied your request. The Plan says this is not covered. 
 
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 an interim 
partial denture (D5820) provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on October 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
member's primary care physician did not refer these services. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for dermatology services provided on October 5, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a hospital 
bed, wheelchair, and commode. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for a hospital bed, wheelchair, and commode.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intrapulmonary percussive ventilator (IPV). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that IPV in the home setting is not covered. 
 
We looked at the file and Medicare rules. The item at issue is an IPV in the home setting. These services are 
not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an intrapulmonary 
percussive ventilator (IPV).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can continue her course of antibiotics and 
continued rehab efforts at a lower level of care. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.