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

 
We decided that the Plan does not have to pre-approve revision of upper eyelid and repair of brow defect for 
the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says photographs of the enrollee's face were not received, or they do not demonstrate 
that the requested procedure is not for cosmetic purposes. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that coverage criteria have been met in this case. The 
documentation does not support that the enrollee has visual field loss of greater than 12 to 15 degrees or a 
visual field deficiency of greater than 24% to 30%. The documentation does not support the potential for 
correction of the enrollee's condition with the requested procedure. The documentation does not support that 
the enrollee in this case has trauma, infection, inflammation, degeneration, neoplasia, or developmental errors 
of the upper eyelid. The documentation does not support that there is visual impairment secondary to redundant 
skin weighing down on upper lashes resulting in eye strain, headache and loss of vision. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve revision of upper eyelid and repair of brow defect for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT oncology assay provided on July 15, 2021. 
 
You asked the Plan to pay for the Tempus xT oncology assay. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim has not been billed with 
the correct POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 Tempus xT oncology assay 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 the Tempus xT oncology assay provided on July 15, 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you appear to not be stable enough for transfer 
at this time. Acute care services can be safely administered at the current facility for the time being until 
treatment is completed and transfer to a lower level of care is more appropriate. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the enrollee has not 
tried and failed zoledronic acid or Pamidronate. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Xgeva. Our physician reviewer found 
that the enrollee is found to have a diagnosis of hypercalcemia of malignancy. The Plan requires a trial of 
zoledronic acid or Pamidronate before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 23, 2021 by an out-
of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 referring provider 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 drug testing provided on November 23, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx test (0037U) provided November 8, 
2021. 
 
You asked the Plan to pay for the FoundationOne CDx test. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the provider did not bill as 
required by Medicare coding regulations. 
 
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 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the Plan confirmed with the 
doctors office that genetic testing was not ordered and that the order was for only for pathology of NGS panel 
on October 20, 2021. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne CDx test have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx test (0037U) provided November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contract language indicating that these services are included in the dialysis rate. The Plan denied 
your request. The Plan says these tests are bundled into the dialysis service. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 18, 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that this admission is medically necessary. 
The Plan denied your request. The Plan says a LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 this device is experimental. More research is needed. 
 
 
 
 
 
 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 Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR (5,10-methylenetetrahydrofolate reductase) 
(eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 81291). 
 
You asked the Plan to pre-approve the genetic testing. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 genetic testing have not been met. Your request is not a 
covered benefit because the enrollee's records show they are 70 years old and do not appear to be pregnant. 
Therefore, we decided that the Plan does not have to pre-approve MTHFR (5,10-methylenetetrahydrofolate 
reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 
81291).
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. You say that this medication has helped improve inflammation 
contributing to your uncontrolled atopic dermatitis. You also say that topical steroids and oral prednisone were 
of little benefit. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of an interstitial device (55876) provided on 
July 29, 2021. 
 
You asked the Plan to pay for the placement of an interstitial device. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the records 
submitted do not include documentation for the billed date of service. 
 
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 placement of an interstitial device 
(55876) provided on July 29, 2021. have been met. Specifically, the documentation submitted does not include 
any clinical information for the billed date of service. Therefore, we decided that the Plan does not have to pay 
for the placement of an interstitial device (55876) provided on July 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says medically necessary care is available in-network. 
 
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 
the home health services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of the abdominal wall services (49900) provided 
on January 24, 2020. 
 
You asked the Plan to pay for the repair of the abdominal wall services. You say that you would like this claim 
reprocessed based on the corrected codes. The Plan denied your request. The Plan says the operative report did 
not include documentation of the service billed. 
 
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 repair of the abdominal wall 
services (49900) provided on January 24, 2020, have been met. In this case, no medical records were provided 
to corroborate the service as billed. Therefore, we decided that the Plan does not have to pay for the repair of 
the abdominal wall services (49900) provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig for the enrollee. 
 
You asked the Plan to pre-approve a wig. You say that this is necessary for the enrollee. The Plan denied your 
request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for items which either meet the 
definition of DME or a prosthesis when these items are ordered by a physician. 
 
In this case, although the wig may be appropriate for the enrollee, it does not meet the definition of the above 
benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not 
meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached 
tissue. As such, it is noncovered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
a wig for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 81479, 
81227, 81230, 81408, 81355 and 81291, 81225, 81226, 81231, 81232, 81401, 0033U, 81283, 81328, 81335 
and 81406 provided May 7, 2021 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached documents. Review 
and reconsider the claim for payment. The Plan denied your request. The Plan says services do not meet 
coverage requirements and do not meet NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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. The medical records 
indicate that the specimen was obtained in an office setting, POS 11. The Plan made multiple attempts to obtain 
additional information from the provider without success. Also, Medicare denies coverage when a laboratory 
assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same 
panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 
Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 
81479, 81227, 81230, 81408, 81355 and 81291, 81225, 81226, 81231, 81232, 81401, 0033U, 81283, 81328, 
81335 and 81406 provided May 7, 2021