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

 
We decided that the Plan does not have to pay for medical services provided on November 30, 2020. 
 
You asked the Plan to pay for the medical services. You say that this claim should be paid because there is no 
requirement that the records have a provider signature. The Plan denied your request. The Plan says that these 
services were not denied because of signature requirements.  Rather, the claim was denied because the enrollee 
was on hospice on the date of service in question. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from February 19, 2021, 
through March 2, 2021 with the with secondary diagnosis N17.0, Acute kidney with tubular necrosis. 
 
You asked the Plan to pay for an inpatient admission provided from February 19, 2021, through March 2, 2021 
with the with secondary diagnosis N17.0, Acute kidney with tubular necrosis. The Plan denied your request. 
The Plan says the additional information requested was not provided to review for payment of DRG 326. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim as billed. Therefore, we decided that the Plan does not have to pay for an 
inpatient admission provided from February 19, 2021, through March 2, 2021 with the with secondary 
diagnosis N17.0, Acute kidney with tubular necrosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says documentation that the insulin treatment regimen requires frequent adjustment must be 
provided. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found it is unclear why 
the daughter who is acting as a health aide cannot check the blood glucose levels with a meter.  There is also little evidence of low blood glucose levels or suboptimal control. Specifically, there is no history 
of low blood glucose levels or symptoms. The enrollee is not taking multiple daily injections of insulin. There 
are no extenuating circumstances delineated clearly for why this request is needed over a glucometer. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis services. 
 
You asked the Plan to pre-approve arthrodesis services. You say that the requested surgical procedures are 
medically necessary and supported by your neurosurgeon. The Plan denied your request. The Plan says the 
medical records do not indicate that the enrollee has had a failure of 3 months of nonoperative therapy. 
 
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 arthrodesis services. Our reviewer says 
that arthrodesis services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The enrollee is noted to have trialed medications; 
however, documentation is not clear on when he had chiropractic treatment and evidence of any physical 
therapy having been tried. Injection therapy was recommended and the results from this are not documented. 
Additionally, detailed documentation is not evident regarding potential impending/inevitable temporary intra-
operative instability. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam provided on May 13, 2021. 
 
You asked the Plan to pay for a routine eye exam. You say that this claim should be covered in full by the Plan. 
The Plan denied your request. The Plan says coverage is not provided for routine vision services rendered by an 
OON provider.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are obtained from a provider in the Plans vision network. 
 
We looked at the file and the Plan's rules. In this case, the services rendered were not obtained from a provider 
in the Plans vision network as required by the Plans contract. Based on this information, we decided that the 
Plan's rules for coverage of a routine eye exam have not been met. Therefore, we decided that the Plan does not 
have to pay for a routine eye exam provided on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member may continue to receive care at the current 
facility until discharge is medically appropriate. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
was admitted with acute hypoxic respiratory failure due to COVID-19 pneumonia. 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 he is not currently receiving but that would be available at the LTACH facility. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time.  There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the request for Intracept intraosseous nerve ablation system at L4, L5 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 8, 2021, to March 4, 2021.  
You asked the Plan to pay for home health services. You say that you have submitted claim and remittance 
forms for review. The Plan denied your request. The Plan says the provider did not submit the RAP claim for 
the services rendered. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, no RAP 
claim has been received as of this date. There is no evidence submitted to approve an exception to this 
requirement.. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from February 8, 2021, to March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on 
September 8, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 0242U Unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an Off Campus Outpatient Hospital setting POS 19. Also, the laboratory 
results submitted indicate the specimen was collected on August 30, 2021, and received by the lab on 
September 1, 2021, therefore, the billed code cannot be verified. It is noted multiple attempts were made to 
obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for 
the laboratory service (CPT code 0242U) provided on September 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that you would rather be at home to 
receive your physical therapy. You also say that you checked yourself out of the hospital due to the poor 
conditions and treatment. The Plan denied your request. The Plan says there is no physician order for the 
requested services. 
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the file does not indicate there is an order 
from your physician for the requested services. Therefore, we decided that the Plan does not have to pre-
approve home health services.  
 
Your complaint about the previous facilitys living conditions is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as acute 
rehabilitation facility, skilled nursing facility, outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (CPT code 81479) provided 
on August 3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the services should be covered. The Plan 
denied your request. The Plan says GeneSight Psychotropic has not been shown to be useful, is not considered 
medically necessary and appropriate, is not covered by Medicare and cannot be approved. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. There is insufficient 
information. we do not have clinical information to support why this testing was ordered or how it will affect 
the member's treatment. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic 
testing (CPT code 81479) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stereotactic radiation treatment management of cranial 
lesion(s) (CPT code 77432) provided on May 26, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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, we have confirmed that code 77432 
is a column II code to column I code 77435. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the stereotactic radiation treatment management of cranial 
lesion(s) (CPT code 77432) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on June 15, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The 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 out of network services provided on June 15, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dextroamphetamine Sulfate extended release capsule. 
 
You asked the Plan to pre-approve Dextroamphetamine Sulfate. You say that the enrollee does well on this 
medication. You also say that the enrollee needs it to help with her fatigue. The Plan denied your request. The 
Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 
Medicare Part B. 
 
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 Dextroamphetamine Sulfate 
extended release capsule.   
Benefits for Dextroamphetamine Sulfate 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 0242U remains not supported. 
 
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 0242U is "Targeted genomic sequence analysis panel, 
solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, 
gene copy number amplifications, and gene rearrangements." 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained.  
 
 
 The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of 
service of a doctor's office (POS 11). 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 pay for laboratory 
services provided to the enrollee on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home rehabilitation grade cycle. 
 
You asked the Plan to pre-approve this equipment. You say that this equipment is medically necessary. The 
Plan denied your request. The Plan says a home rehabilitation grade cycle is classified as exercise equipment 
and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules specifically stated physical fitness equipment and self-help devices are not covered.   
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a home rehabilitation grade cycle.