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

 
We decided that the Plan does not have to pay for laboratory work provided on February 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you would like the records to be reviewed and 
the claim to be reprocessed and paid. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on February 24, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction provided on April 20, 2022. 
 
You asked the Plan to pay for mechanical traction. The Plan denied your request. The Plan says coverage 
extends only to treatment by means of manual manipulation of the spine to correct a subluxation. All other 
services furnished or ordered by chiropractors are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve dentures. You say that your previous dentures were damaged, and you are 
unable to eat. The Plan denied your request. The Plan says a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth #17 (D7240). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have this tooth removed. The 
Plan denied your request. The Plan says the removal of an impacted tooth (D7240) is not covered by your 
routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of impacted tooth #17 (D7240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for physician's services provided on 
February 14, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says services from non-
participating providers are not covered under open access unless preauthorized. 
 
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 
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 an office visit for physician's services provided on 
February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when certain 
criteria are met. 
 
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel (81455) provided on November 18, 
2021.  
You asked the Plan to pay for the genetic testing panel. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says the markers being tested must all be clinically 
actionable for coverage to be approved. 
 
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 genetic testing panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was diagnosed with metastatic renal cancer. Per the National 
Comprehensive Cancer Network guidelines for renal cancer, molecular testing is not needed to dictate 
treatment. The ordered testing was not medically reasonable and necessary for 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 genetic testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing panel (81455) provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve native coronary artery catheterization with left heart 
catheterization. 
 
You asked the Plan to pre-approve native coronary artery catheterization with left heart catheterization. You 
say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 native coronary artery catheterization 
with left heart catheterization. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of recurrent 
chest pain, with cardiac catheterization one year ago showing no significant change in coronary anatomy. Non-
invasive imaging or stress testing has not been performed. Guidelines do not support a need for repeat cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of native coronary artery catheterization with left heart catheterization have not 
been met. Therefore, we decided that the Plan does not have to pre-approve native coronary artery 
catheterization with left heart catheterization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy visits and 4 home health 
skilled nursing visits. 
 
You asked the Plan to pre-approve 7 home health physical therapy visits and 4 home health skilled nursing 
visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 7 home health physical therapy visits 
and 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not have documented, ongoing, skilled nursing needs or 
documented, ongoing, skilled physical therapy needs. The enrollee is functioning at a level commiserate with a 
lower level of care.  As such, the requested, ongoing, home health skilled nursing and home health physical 
therapy services are 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 7 home health physical therapy visits and 4 home health skilled nursing visits 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health physical 
therapy visits and 4 home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services from 
August 17, 2022 forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that the enrollee 
can no longer reside at home alone, an requires placement in a long-term care facility. The Plan denied your 
request. The Plan says the inpatient psychiatric services you are requesting do not meet the requirements for 
approval beginning August 17, 2022. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 inpatient psychiatric hospital 
services. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care. Our physician reviewer found it was not expected this enrollee would improve in a reasonable 
period of time for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower 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 inpatient psychiatric hospital services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services from 
August 17, 2022 forward.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx test provided to the enrollee on December 14, 
2021. 
 
You asked the Plan to pay for the testing. You say that this should be reconsidered for payment. The Plan 
denied your request. The Plan says that there was no unique test identifier by MolDX on the claim. 
 
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. The plan cites the Local Coverage Determination (LCD) - MolDX: Molecular 
Diagnostic Tests (MDT) (L35025) in their denial. The code at issue in this case is Current Procedural 
Terminology 0037U. This LCD states that many codes were removed from the LCD on 6/21/18, including CPT 
0037U. The plan has not cited a valid denial reason for this code. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx test provided to the enrollee on December 14, 2021.  
 
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: 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found you were admitted to the hospital 
with infection of an artificial knee joint and deep vein thrombosis. You are now medically stable with 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure. 
 
You asked the Plan to pre-approve Repatha Sure. You say that the enrollee is currently controlled on Repatha 
Sure, and this is a continuation of the medication. The Plan denied your request. The Plan says Repatha Sure 
can be self-administered and is covered by the pharmacy benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sure.  
 
Benefits for Repatha Sure 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 26, 2021, billed 
with code 81479. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing The 
Plan denied your request. The Plan says this provider has already been paid for genetic testing performed on 
this sample. Payment was previously made for codes 81210, 81235, 81275, 81276, 81295, 81298, 81301, 
81317, 81401, 81194, and 81309 in the amount of $3855.20. No further payment can be made for this single 
code billed on a separate claim for the same testing. 
 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 genetic testing provided on 
November 26, 2021, billed with code 81479. have been met. Specifically, there is no documentation supporting 
that the services described by this single code are distinct from the services that were reimbursed by the Plan on 
a prior claim. Without clear documentation showing that code 81479 refers to a service that has not already 
been reimbursed, coverage for this code cannot be confirmed. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on November 26, 2021, billed with code 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor. 
 
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 criteria for coverage are not met. 
 
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 treat with insulin three 
or more times per day or use an insulin pump.. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6 continuous glucose monitor (CGM) sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says Dupixent is a self-
administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 
Benefits for Dupixent 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extra day of inpatient hospital care 
provided from April 26, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for an extra day of  inpatient care. You say that the doctor did not 
review your test in a timely manner. You say that you should not have to pay for the extra day. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 $345 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from April 26, 2022, to April 29, 2022. You have only been asked 
to pay $345 per day for days 1-3 of inpatient care. The total for your stay is $1,035 ($345 copayment x 3 days = 
$1,035). The inpatient care falls within the Inpatient Hospital Care 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 an extra day of inpatient hospital care provided from April 26, 2022, to April 29, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Eliipta (J3535). 
 
You asked the Plan to pre-approve Trelegy Eliipta. You say that the enrollee taking Trelegy would prevent 
further exacerbations. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Eliipta (J3535).  
 
Benefits for Trelegy Eliipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.