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

 
We decided that the Plan does not have to pay for Oncology (breast), mRNA, gene expression profiling by 
real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as 
recurrence score (Used to report the Oncotype DX Breast test) (81519) provided on June 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the Plan must cover the test consistent with 
LCD L35160. Please immediately reprocess your claim as a covered service. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 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. Also, The appeal letter suggests that LCD L35160 should be referenced, however, that 
LCD does not have jurisdiction over the state of Oregon. 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 Oncology (breast), 
mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin 
embedded tissue, algorithm reported as recurrence score (Used to report the Oncotype DX Breast test) (81519) 
provided on June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided from December 25, 2021, to December 29, 
2021. 
 
You asked the Plan to pay for hospital services. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says that the emergency department charges, related 
ancillary charges, and observation care must be billed separately for payment review. 
 
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 provided an Explanation of Payment but has not 
provided the original claim as it was submitted for payment. Without this information, we cannot verify how 
these services were billed. In addition, the Plan has not provided a specific rule or citation to support their 
argument. The Plans denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for 
hospital services provided from December 25, 2021, to December 29, 2021.  
 
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 pre-approve sedation for 30 minutes (D9222/D9223). 
 
You asked the Plan to pre-approve sedation for 30 minutes. You say that the service is necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
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 pre-approve 
sedation for 30 minutes (D9222/D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your records do not show you that you need rehabilitation nursing 24 
hours a day. 
 
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. You 
are deconditioned. You do not require intensive therapy and do not require frequent physiatry oversight. You do not have complex needs, do not require rehabilitation nursing. You need strength and endurance training, do 
not have loss of limb function, and no autonomic instability. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous radiofrequency ablation of the 
basivertebral nerve. 
 
You asked the Plan to pre-approve basivertebral nerve ablation. You say that this is not investigational or 
experimental given there is sufficient science published in peer-reviewed publications. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this procedure is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve basivertebral nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of basivertebral nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intraosseous radiofrequency ablation of the basivertebral nerve.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 19, 2021, and 
June 15, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration 
because the Plan is responsible for paying 100% of the Medicare Diagnosis Related Group Rate. The Plan 
denied your request. The Plan says an itemized bill and medical records were requested but not provided. 
 
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 on 
May 19, 2021, and June 15, 2021. have been met. Specifically, the documentation submitted does not include 
any medical records or an itemized bill to verify the services at issue. Of note, the record shows that the Plan 
requested this information and it was not received. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital services provided on May 19, 2021, and June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) 
provided on March 15, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says this request is not medically 
necessary because the criteria requirements are not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the non-emergency ambulance 
transportation. Our reviewer says that the documentation did not support that the ambulance transport was 
medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation did not 
support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of 
vehicle) were contraindicated for this enrollee. Our reviewer also found that the documentation did not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance could provide for safe transport on March 15, 2022. 
 
 
 
 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided 
on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from December 21, 2021, to March 1, 
2022. 
 You asked the Plan to pay for acupuncture. You say that you are appealing all acupuncture services by this 
provider. The Plan denied your request. The Plan says you do not meet the Medicare criteria for coverage of 
acupuncture. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that you have chronic low 
back pain required for coverage of acupuncture. Therefore, we decided that the Plan does not have to pay for 
acupuncture provided from December 21, 2021, to March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 17, 
2022, to March 18, 2022. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 17, 2022, to March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myoelectric elbow wrist hand finger orthosis (the 
MyoPro Motion G). 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has right upper extremity partial paralysis after suffering a stroke in 
2015. The enrollee has tried and failed physical and occupational therapy. There is insufficient evidence in the 
literature that the MyoPro orthosis will improve the long term outcomes for this enrollee, improve hemiparetic 
arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested 
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 MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myoelectric elbow wrist hand finger orthosis (the MyoPro Motion G).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0553) and 
receiver (K0554). 
 
You asked the Plan to pre-approve a CGM and receiver. You say that the enrollee's provider prescribed these 
supplies, and the meter is working out well for him. You also say it saves the enrollee from pricking his fingers 
a couple times a day. The Plan denied your request. The Plan says medical records support the enrollee is not 
on insulin therapy and therefore, does not meet the criteria for the supplies. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0553) and receiver (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that your request is not medically necessary because your records show you 
do not have 3 or more daily administrations of insulin or that you need to frequently adjust your insulin dosing. 
 
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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on January 8, 
2022, to January 16, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the cost share 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 a $200 
copayment per day, days 1-6: $0 per day, days 7-90 $0 copay for additional days for inpatient hospital services. 
The total cost share is $1,200.  
 
You have been asked to pay a $200 copayment per day, days 1-6: $0 per day, days 7-90 $0 copay for additional 
days for inpatient hospital services. Inpatient hospital services fall within the inpatient hospital care 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 copayment for inpatient hospital services on January 8, 2022, 
to January 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the office visits provided from March 9, 2022, to 
March 18, 2022. 
 
You asked the Plan to reduce the copayment for the office visits. You say that you were seen by a nurse 
practitioner not a specialist. That you should be charged a $25 copay since a nurse practitioner is not even a 
doctor. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $25 copayment for primary care physician services.  
 
The Plan says you must pay a $100 copayment for two office visits performed by a specialist or nurse 
practitioner. Based on the Plan contract, however, you cannot be asked to pay more than a $50 copayment for 
two office visits by a primary care physician ($25 per visit x 2 visits = $50). Therefore, we decided that the 
Plan has to reduce the copayment for the office visits provided from March 9, 2022, to March 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exploratory surgery and possible repair of gluteal 
tendon. 
 
You asked the Plan to pre-approve exploratory surgery and possible repair of gluteal tendon. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 exploratory surgery and possible repair 
of gluteal tendon. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found 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 exploratory surgery and possible repair of gluteal tendon, 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 exploratory surgery and possible repair of gluteal tendon have not been met. Therefore, we decided that the Plan does not have to pre-approve exploratory surgery and possible repair of 
gluteal tendon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient care provided from March 11, 
2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you did not receive a bill until 
recently. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $175 per 
day for days 1-4 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from March 11, 2022, to March 15, 2022. Therefore, you have 
been asked to pay $175 per day for days 1-4 of inpatient care. The total for your stay is $700 ($175 copayment 
x 4 days = $700). The inpatient care falls within the Inpatient Hospital Care 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 copayment for inpatient care provided from March 11, 2022, to March 15, 2022.