Persius/hicric huggingface dataset:
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 would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient 
Rehabilitation 
Facility (IRF) services you and/or your provider 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for lumbar spinal surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim processed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 a home health visit provided on December 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the scanning computerized ophthalmic diagnostic imaging (92133). We 
decided that the Plan does not have to pay more for the outpatient office visit (99214).  
 
You asked the Plan to pay for the scanning computerized ophthalmic diagnostic imaging (92133) and to pay 
more for the outpatient office visit (99214) provided on February 2, 2022. The Plan says that this claim 
processed correctly. 
 
We decided that the Plan has to pay for the scanning computerized ophthalmic diagnostic imaging 
(92133).  
 
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 contract says that you are responsible for a $10 copay for physician services to diagnose and 
treat diseases and conditions of the eye. 
 
We looked at the file and the Plan's rules. The contract says that you are responsible for a $10 copay for 
physician services to diagnose and treat diseases and conditions of the eye. It is reasonable that you believed 
the imaging provided during the office visit would be covered under the $10 copay. Based on this information, 
we decided that the Plan's rules for coverage of the scanning computerized ophthalmic diagnostic imaging 
(92133) have been met. Therefore, we decided that the Plan has to pay for the scanning computerized 
ophthalmic diagnostic imaging (92133).  
 
We also decided that the Plan does not have to pay more for the outpatient office visit (99214). 
 
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. 
 
We looked at the file and the Plan's rules. You are responsible for a $10 copay. Based on this information, we 
decided that the Plan's rules for coverage of the outpatient office visit (99214) have not been met. Therefore, 
we decided that the Plan does not have to pay more for the outpatient office visit (99214). 
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reclast. 
 
You asked the Plan to pre-approve Reclast. You say that the enrollee has been on Reclast since 2020 and has 
reported good tolerance to treatment. You say that the labs have been submitted and support the need for this 
requested drug. The Plan denied your request. The Plan says that the guidelines for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reclast. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has a medical history that 
includes osteoporosis. Zoledronic acid (Reclast) is a once-yearly intravenous infusion approved for the 
treatment of osteoporosis in men, in postmenopausal women, and in patients with glucocorticoid-induced 
osteoporosis. Zoledronic acid is the most potent bisphosphonate available. It increases bone mineral density 
(BMD) at the spine by 4.3-5.1% and the hip by 3.1-3.5%, as compared with placebo. Over 3 years, it reduces 
the incidence of spine fractures by 70%, hip fractures by 41%, and nonvertebral fractures by 25% in 
postmenopausal women. A similar effect on vertebral fractures has been shown in men. A randomized, 2-year 
trial of men with osteoporosis found that once-yearly zoledronic acid infusions significantly decreased the risk 
of new morphometric vertebral fractures by 67%. A randomized, placebo-controlled, double-blind trial 
suggested that a once-yearly 5-mg dose of IV zoledronic acid increases bone mass in men within 90 days of hip 
fracture repair; similar increases were noted in women. In this case, the enrollee has been receiving Reclast 
since 2020 and has reported good tolerance to treatment. The review has determined that the documentation 
does not support that the Reclast is medically reasonable and necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have been met. Therefore, we decided that the Plan has to pre-approve 
Reclast.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid panel test (80061) provided February 14, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this claim denied for medical necessity in error. 
A total of 4 separate appropriate diagnosis were billed. Medical records are attached for review. The Plan 
denied your request. The Plan says services not covered per Medicare NCD. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lipid panel test (80061) provided 
February 14, 2022. have been met. The records show that the Plan had made multiple attempts to obtain 
additional records from the provider without success. Without the information,. Therefore, we decided that the 
Plan does not have to pay for the lipid panel test (80061) provided February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the records provided 
support the need for the requested inpatient psychiatric care. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the services needed could be provided in a less 
restrictive level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric hospital services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on June 30, 2022, with Mood Disorder with 
Major Depressive-Like Episode Due to General Medical Condition, Major Neurocognitive Disorder, 
Unspecified with Behavioral Disturbance and Substance Abuse. Based upon review the records provided it was 
not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to 
self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care. It did not appear that the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis. She is noted to be cooperative and compliant with 
treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 2, 
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 the enrollee's medical condition did not require approval definitive urine drug testing (UDT) for 
22 or more drug classes (procedure code G0483). 
 
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 there was sufficient information already to manage the enrollee without this testing. The use of 
confirmatory testing should be based on the need to detect specific drug metabolites that cannot be identified 
on standard immunoassays, or on the presence of unexpected presumptive urine drug test results. In addition, 
clinicians should not test for substances when the results would not affect patient management, or for which 
implications for patient management are unclear. Each individual definitive drug class tested must be medically 
necessary, and the results of each drug class tested must be used to treat an active illness or disease, as opposed 
to being used for screening purposes. Ordering a multi-drug panel of definitive (confirmation) urine drug tests 
that are not used in management of the enrollee is not medically necessary. The review has determined that the 
enrollee did not meet the criteria for this testing. 
 
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 drug testing services provided to the enrollee on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure reducing support surface (E0184). 
 
You asked the Plan to pre-approve the pressure reducing support surface. You say that the mattress overlay is 
medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pressure reducing support surfaces are covered when 
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 pressure reducing support surface. 
Our reviewer says that the requested mattress overlay is not medically necessary. Our physician reviewer found 
the records show the enrollee has impaired mobility, but the documentation doesn't support that she is unable to 
make a change in body position to relieve pressure or that she has any current pressure ulcers. 
 
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 pressure reducing support surface have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pressure reducing support surface (E0184).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit provided on February 8, 2022, 
and the electrical stimulation with ultrasound provided from February 8, 2022, through April 21, 2022. 
 
You asked the Plan to pay for the non-spinal manipulation services. You say that you believed that you would 
only need to pay a $15 copayment for these visits. You believe that the electrical stimulation with ultrasound 
has helped your pain and feel that the Plan should cover at least 80% of the cost of these treatments. The Plan 
denied your request. The Plan says your EOC clearly indicates that only manual manipulation of the spine is 
covered. The other treatments provided by the chiropractor are not covered. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit provided on February 8, 2022, and the electrical 
stimulation with ultrasound provided from February 8, 2022, through April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower wheelchair commode (E1399). 
 
You asked the Plan to pre-approve a shower wheelchair commode. You say that you have multiple sclerosis 
and you have fallen while getting in the shower, injuring your hip. You also say you live alone and go weeks 
without a shower because you are afraid to fall again. The Plan denied your request. The Plan says the 
requested item does not serve a medical purpose and is considered a personal convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a shower wheelchair commode (E1399).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183) provided December 14, 2020. 
 
You asked the Plan to pay for hyperbaric oxygen therapy. You say that the records should support the necessity 
of the service in dispute. The Plan denied your request. The Plan says that services not supported without 
required documentation. 
 
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. the Plan has not substantiated their reason to continue to deny. The provider had 
submitted medical records and the waiver of liability for the date of service. The Plan has not specified if their 
reason to continue with their denial is a provider, billing and coding or a medical necessity issue. Therefore, we 
decided that the Plan has to pay for physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183) provided December 14, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on December 27, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene. 
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider intends to treat post-procedure edema from a knee replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of a diagnosis of persistent chronic and severe lymphedema. The provided 
records only document localized edema with history of joint replacement. There is no documentation of a 
failure of a four week trial of conservative therapy for the edema. Based on the medical records provided, there 
is no documentation that the correct device/code is being requested in this case. The device requested in this 
case is used for treatment of lymphedema or chronic venous insufficiency with venous stasis ulcers; the 
provided records do not document lymphedema or chronic venous insufficiency with venous stasis ulcers.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667) for the enrollee.