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

 
We decided that the Plan does not have to pay for the rest home visit rendered on March 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 12 for a home 
visit; however, the file shows that the services were performed in a treatment center. Therefore, we decided that 
the Plan does not have to pay for the rest home visit rendered on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chest CT and abdomen/pelvis CT scans for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that you would like to rule out cancer. The Plan 
denied your request. The Plan says that they did not receive physical exam results that show a reason this study 
is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
CT scans are not medically reasonable and necessary. The enrollee has a heart murmur, asthma, diverticulosis, 
and angioedema who was found to have a SED rate of 126 and 87 both in August of 2022. She reported 
chronic back/knee pain but no other new symptoms and no weight loss. The provided records did not describe 
symptoms, physical findings, or recent first line imaging (ultrasound, x-ray) findings with unusual findings 
suggestive of possible cancer to support this request for advanced imaging. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of the CT scans. 
 
We looked at this physician's review, the file, and Medicare rules. 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 chest CT and abdomen/pelvis CT scans for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroscopic chondroplasty. 
 
You asked the Plan to pre-approve the left knee surgery. You say that it is felt that this treatment is necessary to 
alleviate the enrollee's pain. The Plan denied your request. The Plan says the only recent conservative treatment 
appears to be ibuprofen. Additional non-surgical management should be tried before this request can 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 pre-approve the left knee surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a female being treated for chondromalacia of the left knee. However, detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. The exam from 7/14/22 requested physical therapy for the knee; however, it is not 
clear that this has been tried and failed. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested left knee arthroscopic chondroplasty, 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 left knee surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee arthroscopic chondroplasty.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to the enrollee on January 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that you are working to get the required information. 
The Plan denied your request. The Plan says that medical records were not received. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab services provided to 
the enrollee on January 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
March 31, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that this was billed correctly. The Plan 
denied your request. The Plan says this was billed with an ambulatory surgical center as the place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices were used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on March 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing and Thyroid stimulating hormone 
(TSH) testing provided on December 8, 2021.  
You asked the Plan to pay for the Vitamin D testing and Thyroid stimulating hormone (TSH) testing. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services provided are 
not a covered benefit. 
 
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 Vitamin D testing and Thyroid stimulating hormone (TSH) testing at issue in this appeal were 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 and Thyroid stimulating hormone (TSH) 
testing provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided 
February 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test 
(0037U) provided February 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on March 1, 2022. 
 
You asked the Plan to pay for the F1CDx. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing 
provided on March 1, 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: 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 you are appealing the denial for long-
term acute care hospital admission. The Plan denied your request. The Plan says based on the clinical 
information provided, medical necessity is not met. 
 
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 was admitted on August 13, 2022 with intracerebral and intraventricular 
hemorrhage. 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 MDx testing coded 81479 provided on July 21, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 
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 the MDx testing coded 81479 provided on July 21, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, foot, flexible keel 
(L5972). 
 
You asked the Plan to pre-approve a foot prosthetics. You say that the previous foot is larger than the sound 
side foot. This results in having difficulty donning shoes and you are unable to do so without assistance. The 
foot also has a longer lever arm than is required for you, creating an asymmetrical gait. The toe lever is also too 
stiff for you which increases the adverse pressure on the residual limb from ground reaction forces throughout 
the gait cycle. The Plan denied your request. The Plan says the requested prosthetic components exceed your 
needs as your current foot is under warranty. 
 
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 records show that you were approved for your current foot in 
January 2021, which is still under warranty. The foot has a 36-month warranty; therefore, you have exceeded 
your coverage for a foot prosthetic. Based on this information, we decided that Medicare rules for coverage of 
a prosthetics have not been met. Therefore, we decided that the Plan does not have to pre-approve an all-lower 
extremity prostheses, foot, flexible keel (L5972).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blepharoplasty (eyelid reconstruction) surgery. 
 
You asked the Plan to pre-approve the requested blepharoplasty procedure. You say that this is a medically 
necessary procedure. The Plan denied your request. The Plan says the enrollee does not have ocular 
pathologies that indicate that the visual field will improve with surgery. 
 
The Plan follows Medicare rules. Medicare rules say that functional blepharoplasty procedures may be covered 
when the criteria listed in the Medicare rules section of this decision 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 the requested blepharoplasty procedure. 
Our reviewer says that the documentation does not support the necessity of this surgery. Our physician 
reviewer found the record indicates that the enrollee has droopy eyelids. The record provided does not indicate 
reversible functional deficit from the droopy eyelids. The record provided does not document the presence of 
the enumerated conditions required for coverage. The elements of the coverage criteria are not satisfied.  
 
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 requested blepharoplasty procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a blepharoplasty (eyelid reconstruction) surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 30, 2021, billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321 and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services were not billed in accordance with Medicare rules. 
 
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 December 30, 2021, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 
81301, 81311, 81317, 81321 and 81194.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro electrical arm brace. 
 
You asked the Plan to pre-approve the MyoPro arm brace. You say that this device will help the enrollee to 
function better. The Plan denied your request. The Plan says this is not a proven treatment for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro arm brace. Our reviewer 
says that the requested electrical brace is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that based on the medical records provided and current clinical guidelines, there is no 
documentation that the MyoPro electrical arm brace at issue in this case meets Medicare criteria for medically 
reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. Although records from the device manufacturer/vendor argue medical necessity of the requested 
device, no records from the enrollees actual treating provider clarify why the requested device is the most 
appropriate treatment for the enrollees condition. In addition, the provided records report left upper extremity spasticity which may be a contraindication to use of the device.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MyoPro arm brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro electrical arm brace.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound-guided placement of the Sprint 
percutaneous nerve stimulator (PNS). 
 
You asked the Plan to pre-approve the Sprint PNS placement. You say that this procedure is supported by the 
literature and should be covered. The Plan has used the incorrect rules in denying this request. The Plan denied 
your request. The Plan says this is considered to be experimental per Medicare rules. 
 
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 Sprint PNS placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a female with chronic shoulder pain. This procedure is 
considered experimental/ investigational at this time. Therefore, the request is deemed 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 Sprint PNS placement have not been met. Therefore, we decided that the Plan does not have to pre-approve the ultrasound-guided placement of the Sprint percutaneous nerve stimulator 
(PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator rendered on February 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The file shows that the oxygen equipment has exceeded the 36 
monthly rental payments. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator 
rendered on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services 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, a cardiovascular risk assessment panel, 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 laboratory services rendered on February 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on May 21, 2021, 
and May 28, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you do not feel you should be 
responsible for the cost-share. You say that you've had injections for pain management for 20 years and never 
had a cost-share under previous insurance plans. The Plan denied your request. The Plan says The Plan says the 
coinsurance applied is correct. 
 
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 20% 
coinsurance for chemotherapy and all other part B drugs.  
 
 
  You have been asked to pay $2,467.70, which is 20% of the allowed amount of the injection. An injection to 
the joint falls within the Medicare Part B Prescription Drugs 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 coinsurance for the injection provided on May 21, 2021, and May 28, 2021.