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

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing panel provided on August 
24, 2021. 
 You asked the Plan to pay for the Genesight Psychotropic testing panel. You say that this is a Medicare 
covered test. The Plan denied your request. The Plan says there is not sufficient evidence to support this testing 
is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Therefore, we 
decided that the Plan does not have to pay for the Genesight Psychotropic testing panel provided on August 24, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and infusion services rendered on September 
2, 2020. 
 
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 claim was not billed with the required present on admission (POA) indicator. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of the Present on Admission 
Indicator (POA), even if the outpatient services are bundled with the inpatient claim, hospitals shall code any 
conditions the patient has at the time of the order to admit as an inpatient as POA irrespective of whether or not 
the patient had the condition at the time of being registered as a hospital outpatient.  We looked at the file and Medicare rules. The file shows that the claim was not billed with the required POA 
indicator. 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 pay for the laboratory and infusion services 
rendered on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology breast messenger ribonucleic acid (mRNA) 
provided on October 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oncology breast mRNA. You say that you would like reconsideration because 
the results of this testing will impact the enrollee's treatment. The Plan denied your request. The Plan says there 
is no network deficiency for these services and alternate network providers were found. 
 
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 oncology breast messenger ribonucleic acid 
(mRNA) provided on October 12, 2021 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 dental fillings you received from an out-of-network 
dentist on July 12, 2021. 
 
You asked the Plan to pay for the dental fillings. You say that you have gone to this dentist for 20 years and 
you were told that your dentist took this insurance. You believe these services should be covered because your 
dentist was not aware that he didn't participate with your specific plan. The Plan denied your request. The Plan 
says dental services received from out-of-network dentists are not covered. 
 
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 Plan's contract explicitly 
states that dental services you get from an out-of-network dentist are not covered.  The dentist from whom you 
received these dental services is not part of your dental network.  The Plan cannot be responsible for incorrect 
information provided to you by this out-of-network dentist. 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 dental 
fillings you received from an out-of-network dentist on July 12, 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and should only require short-term additional 
acute care services at the LTACH that can safely be administered at the current facility until appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been an x-ray of the lumbar spine to determine potential alternate causes 
such as a fracture, arthritis, or congenital anomalies. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has back pain radiating to the hip.  The record does not indicate the occurrence of acute injury 
although a fall in summer 2021 is reported. The record does not indicate the presence of any red flag signs and 
straight leg raising was normal. The record indicates that the enrollee is beginning a physical therapy program. 
The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 23, 2021. 
 
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 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 these 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. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy.  
You asked the Plan to pre-approve a colonoscopy. You say that you have had cancer two times and that polyps 
have been found during your past colonoscopies. You say that these things contribute to your being high risk 
and eligible for a colonoscopy every 2 years. The Plan denied your request. The Plan says the medical 
information does not support that the enrollee needs a colonoscopy every 2 years. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that certain indications must be met for an enrollee to be 
considered high-risk for colorectal cancer.  
 
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 a colonoscopy. Our reviewer says that a 
colonoscopy is not considered medically reasonable and necessary at this time. Our physician reviewer found 
the enrollee has a personal history of sub-centimeter tubular adenomas on April 11, 2011, and December 23, 
2016. No polyps were shown to have been colonoscopically detected in April of 2019. The enrollee's last office 
visit with her gastroenterologist dates to May 19, 2020, and the provider's office advised that a face-to-face 
encounter would be needed before additional colonoscopies could be considered. Our physician reviewer found 
that the enrollee is not considered to be high-risk for colorectal cancer according to Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. You are not considered to be at high-risk for 
colorectal cancer based on the medical records provided. This means that you are eligible for a screening 
colonoscopy every 10 years. It has not been 10 years since your last colonoscopy. Based on this information, 
we decided that Medicare rules for coverage of a colonoscopy have not been met at this time. Therefore, we 
decided that the Plan does not have to pre-approve a colonoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
September 29, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the $250 vision allowance was already used for date of service September 29, 2021, in which payment 
went to the provider and the member would not have had to submit for reimbursement. There is no left-over 
payment that the member should receive as it was already covered in a discount and the Medicare allowance by 
the Health Plan leaving the members only responsible for $212.35.  
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the provider the maximum 
eyewear benefit allowance of $250 and you are responsible for $212.35. Therefore, we decided that the Plan 
does not have to pay an additional amount for eyeglasses provided on September 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation indicates you have 
continued to have respiratory decompensation and require skilled services in a long-term acute care hospital 
(LTACH). You continue to require skilled nursing and/or skilled therapy services on a daily basis. There is no 
indication that transfer to a skilled nursing facility is required and you are not currently stable for transfer to a 
lower level of care. There are no services offered at a SNF that are not offered at a LTACH. You continue to 
require skilled nursing services and complex medical care that can be provided at the current LTACH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and more stable but requires short-term 
additional acute care services at the LTACH that can safely be administered at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to a lower level of care may be 
considered when treatment has completed and the enrollee is more stable following weaning trials. 
 
 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no medical diagnosis that meets the coverage criteria for this request. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in 
function.   
 
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 services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found the records indicate 
that you have back and hip pain. The results of the lumbar x-ray demonstrate anterolithesis, or subluxation, of 
L3 and L4. The elements of the coverage criteria are 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 services have been met. Therefore, we decided that the Plan has to pre-
approve chiropractic services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional laser services for cataract surgery provided on July 
14, 2021, and July 19, 2021. 
 
You asked the Plan to pay for additional laser services for cataract surgery. You say that Plan personnel and 
Medicare documents indicated that use of the laser for the procedure was covered. You say that you are 
requesting reimbursement of $1,000 for the additional laser cost for each procedure totaling $2,000. The Plan 
denied your request. The Plan says that laser surgery, premium lenses and/or multifocal lenses are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries will pay additional charges (which 
are non-covered by Medicare as these additional charges are not part of a Medicare benefit category) associated 
with insertion of an astigmatism correcting intraocular lens (AC-IOL) following cataract surgery. 
 
We looked at the file and Medicare rules. Specifically, additional laser services are not a covered benefit. 
Based on this information, we decided that Medicare rules for coverage of additional laser services for cataract 
surgery have not been met. Therefore, we decided that the Plan does not have to pay for additional laser 
services for cataract surgery provided on July 14, 2021, and July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional feature for a prosthetic leg (L5920) for the 
enrollee. 
 
You asked the Plan to pre-approve the additional feature. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested alignable system is not consistent with the function of the 
current, approved preparatory prosthesis. 
 
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 additional feature. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. 
 Our physician reviewer found the requested item exceeds the enrollee's medical need as the enrollee's current 
approved preparatory prosthesis is non-alignable and at this time the alignable system is not appropriate for the 
enrollee's functional level. 
 
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 additional feature have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional feature for a prosthetic leg (L5920) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on May 
21, 2021. 
 
You asked the Plan to pay for the billed services. You say that the monitoring affords the enrollee the best 
medical technology. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. We find that the billed CPT codes 95885, 95955, and 95909 are not 
supported in the medical record. The medical records do not show that the codes at issue were not described in 
the documentation. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative 
neuromonitoring services provided on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator. 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that this is medically necessary. 
The Plan denied your request. The Plan says that you do not have a qualifying condition for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a functional electrical stimulator is covered if 
Medicare criteria have been met. 
 
We looked at the file and Medicare rules. The file does not indicate you are using this to treat muscle atrophy 
where nerve supply to the muscle is intact or being used to help walking because of a spinal cord injury. Based 
on this information, we decided that Medicare rules for coverage of a functional electrical stimulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.