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

 
We decided that the Plan does not have to pre-approve the MyoPro 2 orthotic device. 
 
You asked the Plan to pre-approve the MyoPro 2. You say that you would like reconsideration because this 
device is medically necessary. The Plan denied your request. The Plan says this device is 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 the MyoPro 2. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the member's 
medical condition/function than any available standard therapy. 
 
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 MyoPro 2 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro 2 orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on 
April 17, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like the 
Plan to pay the remaining balance of $80. The Plan denied your request. The Plan says benefits for this service 
are limited to one time per 12-month period. 
 
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, emergency exams are limited to 1 
emergency exam per 12-month period. The record shows that you received a problem focused limited oral 
evaluation on March 16, 2020, and your emergency exams benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation provided on April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 7, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 did not pre-approve the 
services 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 psychotherapy services provided on April 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has reached a plateau. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ventilators are covered for certain conditions. 
 
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 portable ventilator. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found according to the records, this enrollee 
appeared to be stable during the day with the supplemental oxygen only. Night time use of bilevel positive 
airway pressure (BiPAP) appears to be most appropriate at least as a trial rather than a full home ventilator. 
Therefore, this request for such will be considered not medically necessary 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing F2 and F5 gene analysis. 
 
You asked the Plan to pre-approve the genetic testing F2 and F5 gene analysis. You say that the most recent 
documents from the ordering physician and the letter supplied support the medical necessity of the requested 
testing. The Plan denied your request. The Plan says the requested testing 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 genetic testing F2 and F5 gene 
analysis. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee is not pregnant or younger than 50 years old. Our 
physician reviewer found that the documentation provided is not specific as to how the results of FVL and F2 
testing would change the clinical management of the enrollee. The documentation does not support that the 
requested testing is medically necessary, reasonable, and 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 the genetic testing F2 and F5 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genetic testing F2 and F5 gene analysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier services provided on 
May 17, 2019. 
 
You asked the Plan to pay for Percepta Bronchial Genomic Classifier services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percepta Bronchial Genomic Classifier testing is only 
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 pay for Percepta Bronchial Genomic Classifier 
services. Our reviewer says that the documentation does not support that the services rendered were medically 
reasonable or necessary. Our physician reviewer found the enrollee was noted to have a lung lesion, which 
needed to be biopsied. The lesion could not be biopsied via a BAL. As there was a suspicion of cancer, the 
enrollee was to be referred to CT surgery for further removal/diagnostics. It does not appear that the result of 
the Percepta genetic test was going to be used to determine the next course of action. Therefore, the enrollee 
did not meet criteria for the rendered 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 Percepta Bronchial Genomic Classifier services have not been met. Therefore, 
we decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier services provided on 
May 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health 
problem. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is needed to 
show safety and efficacy. It is not the gold standard for fusion 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after 
September 14, 2020. 
 
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve continued SNF coverage. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee was discharged 
from physical therapy and occupational therapy on September 1, 2020. The enrollee was non-weight-bearing 
on the right lower extremity. The documentation does not support that the enrollee requires the specialized 
skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing 
or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis, at a SNF 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 continued SNF coverage have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) coverage after September 14, 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 you can safely receive the services you need in other settings. 
 
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 rib fractures and a pelvic 
hematoma after a motor vehicle collision. Your medical problems are stable. 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. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 12, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says Medicare 
covers the device for inside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The records provided show that the scooter at issue in this appeal is for use outside of the home. The 
documentation provided shows the enrollee's home is not open and accessible for the requested device. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on April 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you were told this was free from the government. 
You say that you don't know how they got your insurance information because you did not give it to them. 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 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 genetic testing provided on April 2, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of a pump with oxygenator or heat 
exchanger (99190) provided March 20, 2020. 
 
You asked the Plan to pay for The assembly and operation of a pump with oxygenator or heat exchanger (. You 
say that these charges are for the perfusionist that setup and operated the heart-lung machine for this enrollee's 
surgery. The Plan denied your request. The Plan says payment for this service would be included in the part-A 
DRG payment to the facility. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. The enrollee was an inpatient, therefore all services provided to the enrollee will be paid under the 
global facility claim. Payment for the perfusionist's service would have been included under the facility claim. 
Payment to the perfusionist for this service is the responsibility of the facility or hospital. Based on this 
information, we decided that Medicare rules for coverage of  the assembly and operation of a pump with 
oxygenator or heat exchanger ( have not been met. Therefore, we decided that the Plan does not have to pay for 
assembly and operation of a pump with oxygenator or heat exchanger (99190) provided March 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 24, 2020 to 
April 7, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required 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 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 24, 2020 to April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve electroretinography (0509T). 
 
You asked the Plan to pre-approve the electroretinography. You say that you would like reconsideration 
because the member has a covered indication for this service. The Plan denied your request. The Plan says that 
ERG for glaucoma is investigational 
 
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 electroretinography. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found per Medicare's LCA,  the enrollee has a covered indication for ERG: Glaucomatous 
optic atrophy, bilateral. 
 
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 electroretinography have been met. Therefore, we decided that the Plan has 
to pre-approve electroretinography (0509T).  
 
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.