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

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx (F1LCDx) testing provided on May 9, 
2022. 
 
You asked the Plan to pay for the F1LCDx testing. You say that this testing is medically necessary and should 
be reimbursed. The Plan denied your request. The Plan says that criteria for this testing are not met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology testing that has been FDA-
approved is nationally covered for advanced cancer patients when the testing is used for the FDA-approved 
indication. 
 
The FDA approval of this testing lists prostate cancer as a covered indication. 
 
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 F1LCDx testing. Our reviewer says that 
the testing provided is considered medically necessary. Our physician reviewer found the enrollee is a male 
who was diagnosed with advanced metastatic prostate cancer. FoundationOne Liquid CDx was performed to 
help determine the course of treatment. The FoundationOne Liquid CDx test is used to test the blood of patients 
with metastatic castration resistant prostate cancer or non-small cell lung cancer. However, if the specific 
mutations in the BRCA1, BRCA2, or EGFR genes are not found, then the patients eligibility for treatment of 
their cancer with the specific drugs should be determined by testing their tumor tissue specimen with an FDA 
approved tumor tissue test, unless a tumor biopsy cannot be done. As this patient has an FDA-approved 
indication with current supportive evidence to support its use in this clinical situation, the FoundationOne 
Liquid CDx will be considered 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 F1LCDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne Liquid CDx (F1LCDx) testing provided on May 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on November 2, 2022. 
 You asked the Plan to pay for the refraction. You say that you were unaware that you would have to pay for the 
refraction. The Plan denied your request. The Plan says the service was not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received with a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on November 2, 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 can improve and benefit 
from an LTACH. You say that the enrollee cannot be adequately care for in their condition at a skilled nursing 
facility as they require direct daily physician assessment, which cannot be performed remotely. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can get 
the services they need in another setting. 
 
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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 you recently fell and need rehab in order to regain 
maximum function. The Plan denied your request. The Plan says the services you need can be provided safely 
in another setting, 
 
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 there are no acute rehab nursing needs identified or documented. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical, multiple post collar, occipital/mandibular 
supports, adjustable orthosis provided on July 20, 2022. 
 
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 the documentation submitted did not sufficiently support the billed supply code. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesn't indicate that the enrollee has significant disease of the 
cervical spine that would require treatment with the requested cervical collar. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for a cervical, multiple post collar, occipital/mandibular supports, adjustable orthosis provided on 
July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve radiation therapy to be provided by an out-of-network provider. You say 
that the care is medically necessary. The Plan denied your request. The Plan says the Plan has in-network 
providers that can treat the members condition. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve radiation 
therapy to be provided by an out-of-network provider.
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 the enrollee is very motivated and would greatly 
benefit from the intensity that IRF setting would provide. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical therapy, there is no documented need for intensive rehabilitation services. 
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 acute inpatient rehabilitation facility (IRF) admission and services.
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 enrollee is a fall risk and needs rehabilitation to 
gain their strength back. The Plan denied your request. The Plan says custodial care is not a covered benefit 
under Medicare or the Plan.

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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, E0656).

You asked the Plan to pre-approve a pneumatic compression device. You say that this item is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, E0656).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 41 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you have not had any problems getting 
authorized services before. The Plan denied your request. The Plan says that the remaining 41 therapy 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 therapy services. 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 that the requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. You can 
transition to a home exercise program with the already extensive approved therapy sessions. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 41 physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 6, 2022, to October 24, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee should not 
be responsible for the cost sharing applied to this service. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment per admission, for each medically necessary inpatient stay. 
 
The enrollee has been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls 
within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided from October 6, 2022, to October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the sales tax (S9999) applied on June 28, 
2022. 
 
You asked the Plan to issue reimbursement for the sales tax. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says sales tax charges are not eligible 
for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors do not make any additional payment 
for sales tax and do not make adjustments in fees to reflect local changes in tax rates. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Specifically, the tax fees applied are not eligible for  
reimbursement. Therefore, we decided that the Plan does not have to issue reimbursement for the sales tax 
(S9999) applied on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) provided on 
September 8, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code G0463 is not supported in the medical record. Specifically, the code at issue has been 
billed with primary diagnosis code Z68.41, Body mass index [BMI] 40.0-44.9, adult. This code is unacceptable 
as a primary diagnosis. Based on this information, we decided that Medicare rules for coverage of hospital 
outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
outpatient clinic visit (G0463) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 13, 2022 and 
March 14, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the medical records submitted don't support a detailed interval history and medical decision making of high complexity. This means the service cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 
 
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 care have been met. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on  
March 13, 2022 and March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim implant abutment placement (D6051x4), a 
custom fabricated abutment (D6057x4), an abutment supported porcelain/ceramic crown (D6058x4) and an 
interim retainer crown (D6793x7). 
 
You asked the Plan to pre-approve dental services. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the requested procedure codes are not listed and 
therefore, not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 an 
interim implant abutment placement (D6051x4), a custom fabricated abutment (D6057x4), an abutment 
supported porcelain/ceramic crown (D6058x4) and an interim retainer crown (D6793x7).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a myocardial perfusion study. 
 
You asked the Plan to pre-approve a myocardial perfusion study. The Plan denied your request. The Plan says 
that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that myocardial perfusion imagine is covered of the 
indications established in the applicable LCD.  
 
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 myocardial perfusion study. Our 
reviewer says that the requested myocardial perfusion study is medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee is a 59-year-old male with a history of diabetes mellitus, chest 
pain, peripheral artery disease, abnormal electrocardiogram (EKG), and improvement of symptoms with 
nitroglycerin. He has predisposition, and an EKG and clinical symptoms are suggestive of coronary artery disease. As such, the requested myocardial perfusion study is medically reasonable and 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 a myocardial perfusion study have been met. Therefore, we decided that the 
Plan has to pre-approve a myocardial perfusion study.  
 
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.