Persius/hicric huggingface dataset:
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the 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 continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that are not 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of chiropractic care with an out of 
network (OON) provider. 
 You asked the Plan to pre-approve the continuation of care with an OON chiropractor. You say that the 
requested OON provider has been the enrollee's doctor for close to 30 years and he has extensive knowledge of 
her medical history, as well as how her body functions. The Plan denied your request. The Plan says the 
services needed are available with in-network providers. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continuation of care with an OON 
chiropractor. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the enrollee has segmental and somatic dysfunction of the thoracic, lumbar, and sacral regions, 
as well as spondylosis without myelopathy or radiculopathy in the lumbar region. The enrollee's current 
chiropractor writes that the enrollee has been an active patient in the office for several years, and that seeking 
care with a new provider will bring on additional stress.  The available documentation does not support that it 
is medically necessary for this enrollee to continue care with the out-of-network provider. There is nothing 
unique about the enrollee's condition that would make it medically necessary for her to continue care with the 
OON provider. The Pan has shown that they have in-network specialists who have the qualifications and 
expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's 
condition. 
 
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 continuation of care with an OON chiropractor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of chiropractic care with an 
out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132) 
and psychological or neuropsychological test administration and scoring (96138). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring. You say that the enrollee requires NeuroTrax memory 
testing due to the worsening of his memory with confusion. You also say that this test will help you rule out 
Dementia as a cause of the enrollee's symptoms. The Plan denied your request. The Plan says these services are 
not medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that testing which is intended to diagnose and characterize 
the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
 
 
 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 neuropsychological testing evaluation 
services and psychological or neuropsychological test administration and scoring. Our reviewer says that this 
request for neuropsychological testing is not medically necessary or reasonable. Our physician reviewer found 
the documentation shows the enrollee claims having memory impairment for the past 2 years, while the 
enrollee just recently had a computerized cognitive test (NeuroTrax). This neurologic exam showed the 
enrollee to have difficulty with being repetitive in words. Our reviewer found that the enrollee was found to be 
oriented to person place and time without any extreme neurologic difficulties. Our physician reviewer also 
found that this patient does not meet the criteria as a patient is not showing severity of symptoms that would 
warrant this type of diagnostic treatment and is therefore not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neuropsychological testing evaluation services (96132) and psychological or 
neuropsychological test administration and scoring (96138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiation oncology service provided on March 10, 2022, by 
an OON provider. 
 
You asked the Plan to pay for a radiation oncology service. You say that you were referred to this provider for 
radiation treatment and would not have gone if they did not think it was authorized. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
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 a radiation oncology service provided on March 
10, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic and GeneSight MTHFR genetic 
testing provided on March 29, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the GeneSight Psychotropic and 
GeneSight MTHFR genetic testing provided on March 29, 2022, have been met. There are no medical records 
in the case file in regard to the physicians intent that the test be performed prior to services taking place. 
Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic and GeneSight 
MTHFR genetic testing provided on March 29, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the 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 continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that are not 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (code 
D7953). 
 
You asked the Plan to pre-approve the bone graft. The Plan denied your request. The Plan says the bone graft is 
not covered by the supplemental benefit. 
 
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 the 
bone replacement graft for ridge preservation - per site (code D7953).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 21, 2022. 
 
You asked the Plan to pay for the genetic testing (0037U). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing (0037U) have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 
21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 18, 
2022, to February 19, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient hospital have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee's vitals were stable prior to and after the procedure which was 
without complication. There was no clinical indication that the patient would require hospital services that were 
likely to cross 2 midnights based on the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 18, 2022, to February 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal vaccine services provided on February 
14, 2022. 
 
You asked the Plan to pay for the meningococcal vaccine services. You say that you would like this medically 
necessary service reprocessed and approved for payment. The Plan denied your request. The Plan says this is 
not covered as a preventative service by Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the meningococcal 
vaccine services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the meningococcal 
vaccine services. Therefore, we decided that the Plan does not have to pay for the meningococcal vaccine 
services provided on February 14, 2022.  
 Benefits for the meningococcal vaccine services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95806). 
 
You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says the records do 
not show that the enrollee has signs and symptoms of obstructive sleep apnea. 
 
The Plan follows Medicare rules. Medicare rules say that polysomnography (PSG) is covered when used to aid 
the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms 
indicative of OSA 
 
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 sleep study. Our reviewer says that a 
sleep study is not reasonable and necessary. Our physician reviewer found the provided documentation does 
not explain why the study was ordered. There was no complaint of symptoms suggestive of sleep apnea 
uncontrolled, no uncontrolled hypertension, no headaches, no daytime sleepiness, et cetera. Our reviewer found 
that therefore, there does not appear to be a condition indicated for coverage nor are there limitations listed in 
the National Coverage Determination (NCD) that would prevent coverage. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95806).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the astigmatic keratotomy services. 
 
You asked the Plan to pre-approve the astigmatic keratotomy services. You say that this procedure performed 
in both eyes would improve your ability to see and quality of life. The Plan denied your request. The Plan says 
any services done for the correction of vision are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules say that the use of radial keratotomy and/or 
keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to 
eyeglasses or contact lenses, which are specifically excluded from coverage. While this service may be 
beneficial for you, neither Medicare nor the Plan covers this service. Therefore, we decided that the Plan does not have to pre-approve the astigmatic keratotomy services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 pre-approve SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document that services in the home or an assisted living facility with home 
health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 for the enrollee. 
 
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 this member does not have complex nursing or medical needs requiring 
a resource intensive inpatient hospital setting. 
 
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. The 
enrollee does not require and cannot be expected to participate in or respond to intensive therapy. He is de-conditioned and frail from metastatic cancer and chemotherapy. He does not have complex rehabilitation needs 
and does not frequent oversight from a physiatrist. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on December 29, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation submitted did not 
support the critical care services 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
specifically indicate that between 30-74 minutes was spent performing critical care services. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on 
December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kits purchased on January 23, 
2022, and January 28, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kits. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says these tests are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 home test kits are OTC items. The Plan had no supplemental coverage for COVID-19 home test 
kits when they were purchased. Therefore, we decided that the Plan does not have to pay for the COVID-19 
home test kits purchased on January 23, 2022, and January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 billed on March 16, 2022. 
 
You asked the Plan to pay for procedure code 96401. You say that medical records are attached, and CPT code 
96401 should be paid. The Plan denied your request. The Plan says there is a more appropriate procedure code 
for the service performed. 
 
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 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 96401. Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
medical record documents Evenity 210mg injections for osteoporosis. The service documented in the medical 
record was incorrectly coded. There is a more appropriate therapeutic procedure code that should be reported in 
this case.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 96401 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 96401 billed on March 16, 2022.