Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 18, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. 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 the 
FANCC gene, the denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
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 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 18, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of the authorization for 
acute inpatient rehabilitation facility admission. The Plan denied your request. The Plan says based on 
Medicare guidelines the services you are requesting do not meet the requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for cholecystectomy. Medical problems are stable. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the records provided support the need for Botox. The 
Plan denied your request. The Plan says the documentation provided does not indicate a diagnosis of urinary 
incontinence due to neurogenic bladder after documented failure of medical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found interstitial cystitis with urgency of 
urination is not an FDA-approved use for Botox. The use of Botox for interstitial cystitis with urgency of 
urination is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The use of Botox for interstitial cystitis with urgency of urination does not meet 
Medicare criteria for safe and effective and otherwise reasonable and necessary for this 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 12, 2021, to March 21, 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 upon appeal, the medical records and itemized bill were not provided after multiple attempts to 
obtain. 
 
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 inpatient hospital services provided to the enrollee from March 12, 2021, to March 21, 2021. have been met. There appear to have been multiple 
attempts to send in relevant medical records for this appeal. The provider has not sent in the information to 
corroborate the necessity of these inpatient services. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from March 12, 2021, to March 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee needs 12 additional PT visits 
according to the signed doctor order. The Plan denied your request. The Plan says the additional PT visits are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation shows that the enrollee is participating in 
various exercises. The reviewer found that there is no documentation as to rational for further skilled therapy is 
needed. Therefore, the reviewer found that 12 additional physical therapy sessions are not medically 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy (PT) visits.
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 based on the enrollee's current care 
requirements you have determined that the enrollee will benefit from and improve with LTAC services with an 
expected length of stay greater than 25 days. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the health care setting where they are currently 
receiving care. The Plan has approved ongoing care in the current acute care setting. 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
endodontic therapy (D3330) provided on April 26, 2022, and April 27, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you had to use an OON endodontist because the 
Plan does not have any in-network endodontists. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and endodontic therapy (D3330) provided on April 26, 2022, 
and April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of mini-implant (D6013) and implant 
supported porcelain/ceramic crown (D6065) provided March 25, 2022. 
 
You asked the Plan to pay for the mini-implant and implant supported crown. You say that implants are 
covered under your benefits. The Plan denied your request. The Plan says these services are not covered under 
your 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 pay for the 
surgical placement of mini-implant (D6013) and implant supported porcelain/ceramic crown (D6065) provided 
March 25, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve non-emergency transportation (A0100) and ground mileage 
(A0425). 
 
You asked the Plan to pre-approve the non-emergency transportation and ground mileage. You say that you are 
having many problems going to doctors visits. The Plan denied your request. The Plan says that the records do 
not show that your care with the treating provider was approved by the Plan. 
 
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. Specifically, the Plan has not provided applicable documentation to show that 
this provider is out-of-network. The Plan has not forwarded any evidence to support that the criteria for 
coverage have not been met. Of note, the Plan has stated that this service is denied because prior authorization 
was not obtained. The record shows that this request is for prior authorization. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the Plan has not substantiated their denial so we 
must find in your favor. Therefore, we decided that the Plan has to pre-approve non-emergency transportation 
(A0100) and ground mileage (A0425).  
 
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 pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that you have no feeling in your right hand and 
need to check her blood sugar. The Plan denied your request. The Plan says that this request is not medically 
necessary because you do not use insulin three or more times daily or require frequent adjustments of the 
insulin dose. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor (CGM) supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide further reimbursement for out-of-network dental services.  
 
You asked the Plan to fully reimburse you for dental services. You say that you were only partially reimbursed 
for the services you received. You asked the Plan to reimburse you for the remainder of charges you paid at the 
point of service. The Plan denied your request. The Plan says the reimbursement was processed correctly.  
 
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. Your contract with the Plan 
clearly says that you must pay a 20% coinsurance for out-of-network supplemental preventive dental services 
and a 50% coinsurance for out-of-network supplemental comprehensive dental services.  
 
 We find the Plan refunded you the correct amount based on the contract rules. Therefore, we decided that the 
Plan does not have to provide further reimbursement a comprehensive oral evaluation (D0150) rendered on 
January 12, 2022, and a partial upper (D5213) and lower (D5214) denture provided on March 25, 2022, by an 
out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage per statute mile (A0425) provided on April 
10, 2022. 
 
You asked the Plan to pay for ground mileage. You say that the ambulance services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the available records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 54.3 units of CPT code A0425 are not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of ground mileage have not been met. Therefore, we decided that 
the Plan does not have to pay for ground mileage per statute mile (A0425) provided on April 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was bed ridden for 11 days and they 
need inpatient rehabilitation to learn to walk again. The Plan denied your request. The Plan says based on 
Medicare guidelines the IRF services you are requesting do not meet all the requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the enrollee was admitted for respiratory failure and pneumonia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 the IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HHA four (4) hours a day, seven (7) days a week. 
 
You asked the Plan to pre-approve the HHA services. You say that you need HHA Services due to vertigo, 
incontinence bowel/urine, chronic back pain, headaches, falls in the bathroom, and need assistance with 
medications. The Plan denied your request. The Plan says additional hours are considered custodial care, which 
is not a covered benefit by the Centers for Medicare and Medicaid Services (CMS). 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 HHA services. Our physician 
reviewer found the approved home health aide services for 3 hours a day for 7 days a week should be sufficient to address your deficits with regards to providing assistance with daily activities and ensuring compliance with 
your medication regimen. Therefore, the additional home aide services for 1 hour a day for 7 days a week is not 
medically 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 HHA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the HHA four (4) hours a day, seven (7) days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for pathology testing provided 
on February 18, 2022. 
 
You asked the Plan to be reimbursed an additional amount for pathology testing. The Plan denied your request. 
The Plan says you were reimbursed the Plan share of the cost. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
We looked at the file and the Plans rules. The file shows you were reimbursed the Plan share of the cost. 
Therefore, we decided that the Plan does not have to reimburse you an additional amount for pathology testing 
provided on February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Centers for 
Medicare and Medicaid Services criteria for an appropriate LTACH admission and clinical documentation is 
attached for reconsideration. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition they do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the health care setting where they are currently 
receiving care. The Plan has approved ongoing care in the current acute care setting. 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 LTACH services.