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

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says none of the clinical information supports a K3 level of ambulation. 
 
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 that the documentation provided does not support the use of a K3 level flex walk system for the patients 
transtibial prosthesis. The patient requires a replacement prosthesis and components due to age and being in 
disrepair. However, there is insufficient clinical documentation regarding the patients current level of mobility 
and function and why he requires a prosthesis with K3 components when he is noted to use a cane for 
assistance for mobility. There are limited physical examination findings in terms of strength and range of 
motion and an assessment tool or inventory regarding the patients potential K level. This information is 
needed to determine if the requested prosthetic flex walk system is appropriate 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex walk system (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement air mattress. 
 
You asked the Plan to pre-approve a replacement air mattress. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested item cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment is no 
less than five years. 
 
We looked at the file and Medicare rules. Review of the file shows that you Based on this information, we 
decided that Medicare rules for coverage of a replacement air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement air mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
admission and can be adequately cared for in her current condition. The Plan denied your request. The Plan 
says based on Medicare guidelines the long term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on 
September 28, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that the FoundationOne Liquid 
CDx testing was medically necessary. The Plan denied your request. The Plan says the FoundationOne Liquid 
CDx testing was 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 FoundationOne Liquid CDx testing. Our 
reviewer says that the FoundationOne Liquid CDx testing was not medically necessary. Our physician reviewer 
found the review has determined that the enrollee does not meet the NCD criteria for the provided 
FoundationOne Liquid CDx testing. The criteria provided by Foundation Medicine NCD 90.2 criteria in the 
appeal documentation, indicates if Next Generation sequencing has already been approved and completed 
utilizing the Oncotype DX AR-V7 Prostate, it should not be re-tested. 
 
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 FoundationOne Liquid CDx testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on September 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve laboratory services. The Plan denied your request. The Plan says these lab 
tests can be performed in-network and the results can be shared with the out-of-network lung transplant center. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve laboratory 
services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transperineal placement of biodegradable material, peri-
prostatic, single, or multiple injection(s), including image guidance, when performed (55874). 
 
You asked the Plan to pre-approve a SpaceOAR Hydrogel Spacer. You say that the enrollee was seen  and received a recommendation for a 5-fraction course of radiation to the prostate using an SBRT technique. As this treatment is delivered at a higher dose per fraction, SpaceOAR and fiducials are important to reduce the risk of toxicity to the rectal wall and safely deliver this treatment. The enrollee would benefit from SpaceOAR and fiducial placement. The Plan denied your request. The Plan says the Medicare criteria for that a periprostatic hydrogel spacer (SpaceOAR) is not met and the request is therefore 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 SpaceOAR Hydrogel Spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the NCCN guidelines do not assign a level of evidence to the use of 
hydrogel spacers or describe what risk groups would be most apt to benefit. While the guidelines explicitly 
state that spacers could be used when other modalities are insufficient, the lack of sufficiency is subjective. 
Based on level 1 evidence (in which all men received image guided radiotherapy), one could assert that using 
hydrogel spacers for routine cases is likely to be beneficial.  The LCD criteria are not met, as the criteria are 
explicit in which risks groups are covered and also the need to use SpaceOAR when other techniques would be 
insufficient due to anatomic geometry precluding meeting normal tissue constraints, anticoagulant use or 
comorbid conditions. This enrollee is being offered SBRT, and there is no specific reason as to why this alone 
(i.e., without SpaceOAR) would be insufficient in this specific enrollee and the LCD criteria specify need only 
for conventionally fractionated or moderately hypofractionated radiotherapy. 
 
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 SpaceOAR Hydrogel Spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transperineal placement of biodegradable material, peri-prostatic, single, 
or multiple injection(s), including image guidance, when performed (55874).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 25, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the collection of venous blood by venipuncture (36415), and basic 
metabolic panel (80048) provided on May 5, 2022. 
 
You asked the Plan to pay for the routine venipuncture and basic metabolic panel. You say that you have been 
going to this provider for years. The Plan denied your request. The Plan says that this service is not covered 
because it was provided OON. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case the Plan failed to provide the Evidence of Coverage or any 
additional documentation to support their denial. Therefore, we decided that the Plan has to pay for the 
collection of venous blood by venipuncture (36415), and basic metabolic panel (80048) provided on May 5, 
2022.  
 
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: 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 you feel that you need the rehab services to fully 
function enough to return home. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 Receiver. You say that you are a diabetic and need this 
device due to you are unable to use needles. The Plan denied your request. The Plan says you do not require 
insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom 
G7 Receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G7 Receiver.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 16, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351 and 81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 16, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 
81351 and 81437.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion procedure (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you hope for a favorable outcome to 
approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. 
The Plan denied your request. The Plan says There are not enough studies on Vertiflex Superion to show it is 
safe and effective. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Vertiflex Superion procedure (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D testing (82306) provided on March 23, 2022. 
 
You asked the Plan to pay for the vitamin D testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says screening tests are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the vitamin D testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the vitamin D testing (82306) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM) and supplies. The Plan 
denied your request. The Plan says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) and supplies. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP MIS interspinous fusion device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
interspinous device to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Aurora Spine ZIP MIS interspinous fusion device, in this 
case, is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Aurora Spine ZIP MIS interspinous fusion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for telehealth. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services must be provided by in-network providers. 
 
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 
an out-of-network referral for telehealth.