Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter COVID-19 home tests purchased on
January 6, 2022.
You asked the Plan to pay for these home test kits. You say that these testing supplies should be covered by the
Plan. The Plan denied your request. The Plan says the decision to deny coverage is correct. The Plan states that
the contract addendum for coverage of COVID-19 home test kits was sent to all enrollees and indicates that
coverage would be provided beginning on January 15, 2022, unless the test was specifically ordered by a
physician. A purchased at-home COVID-19 test was not a covered benefit on January 6, 2022.
The Plan must follow Medicare rules. The rules say that plans were given the option to cover COVID-19 home
testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan communicated to
enrollees that this testing would be covered as a supplemental benefit, free of charge, after January 15, 2022,
unless the testing was required prior to that date due to physician intervention. The medical records do not
show you saw your physician on January 6, 2022. In fact, the medical records show you did not see your
physician until January 11, 2022. Furthermore, Medicare did not cover purchased or over the counter COVID-
19 home testing kits until April 4, 2022. Your purchase was made prior to both dates without physician
intervention. Therefore, we decided that the Plan does not have to pay for over the counter COVID-19 home
tests purchased on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 genetic testing 
provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve an MRI. You say that this imaging is medically necessary. The Plan denied 
your request. The Plan says the requested MRI is not medically necessary as the enrollee recently had 
computed tomography of this area which showed no new issues. 
 
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 an MRI. Our reviewer says that the 
requested MRI is not medically necessary in this case. Our physician reviewer found that the enrollee has low 
back pain and radicular symptoms for which she is on long-term medication. The plain films show fusion 
without boney union at L3-4. There are no red flags such as concern for infection or neurological deficit 
documented. An order for computed tomography (CT) of the lumbar spine was included and signed, but no 
result of this imaging is included in the records and the exam is never mentioned in any follow-up notes. There 
is a note that says four sessions of physical therapy were done but the enrollee was told to stop due to the 
development of cellulitis. No physical therapy notes or details were included. Without the results of the ordered 
CT, any notes from physical therapy and a lack of any other red flags, the medical necessity of the requested 
MRI has not been established. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an 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 (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this would deter hospital admissions. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for the requested purpose, and the 
enrollee's needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation of portable x-ray equipment provided on May 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transportation of portable x-ray equipment. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 transportation of portable x-ray equipment 
provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 9, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing detects actionable oncologic targets. 
The Plan denied your request. The Plan says the service is not supported by the procedure codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2021. 
 You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare and is 
supported in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place 
of service on the claim. In addition, panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The rules also say that if one laboratory procedure evaluates multiple genes using a next generation 
sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing 
procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary 
laboratory analysis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab 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. In addition, this was an NGS 
panel that was not billed with a single panel code as required. Therefore, we decided that the Plan does not 
have to pay for lab services provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance-guided focused ultrasound surgery 
(0398T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the clinical sent in for the authorization 
request was clear that the enrollee met the Medicare criteria. The requirement is met per the Medicare 
guidelines, the enrollee is refractory to medicine and is not a candidate for deep brain stimulation. The Plan 
denied your request. The Plan says the enrollee died not meet the Medicare criteria for Magnetic Resonance-
guided Focused Ultrasound surgery. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the local coverage determination enumerates the conditions and limitations of the 
availability of coverage for the requested service. In this case, the record indicates that the enrollee has benign 
essential tremor of onset in the last year. The record does not indicate that the enrollee has disabling tremor that 
is refractory to at least two medication trials and is not a candidate for medical reasons for deep brain 
stimulation. The elements of the coverage criteria are not satisfied and the requested service is not 
recommended. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance-guided focused ultrasound surgery (0398T).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray services provided on May 12, 2022. 
 
You asked the Plan to pay for the services provided. You say that you do not have access to hospital records. 
The Plan denied your request. The Plan says that it is inappropriate to bill an outpatient place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. We find that procedure code 74018 was billed with an outpatient hospital 
place of service code, 22. The case file does not include any documentation to show that the enrollee was 
receiving inpatient hospital care at the time the service at issue was provided. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for the x-ray services provided on May 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can manage the enrollee's 
complex medical needs with the assistance of licensed staff and daily physician visits. You say the enrollee 
requires the LTACH level of care and is stable for discharge to that level of care. The Plan denied your request. 
The Plan says it is not medically necessary for the enrollee to move to LTACH for ongoing acute level care. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 20, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that this service does not require a 
referral or preauthorization. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 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 subsequent nursing facility care provided on July 
20, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee had already established care with 
the physician and wishes to continue seeking services for this condition under this physician at this location. 
The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 laboratory services provided on July 13, 2022, by 
an out-of-network (OON) 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows active comorbidities but there are no complex functional 
deficits specified and therapy notes do not show that the enrollee would tolerate 15 hours of therapy per week 
thus IRF criteria not met. The complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for discharge but it 
not they are not medically ready for a lower level of care. The Plan denied your request. The Plan says the 
guidelines for LTACH admission were not met and the enrollee is receiving the care that they need in the 
current hospital 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 the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary at this 
time as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (AFO) with insert to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve ankle-foot orthosis (AFO) with insert. You say that you are really suffering 
and need this device. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and the needed items can be supplied by an in-network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ankle-foot orthosis (AFO) with insert to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) and components (E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, and E2603) for the enrollee.
You asked the Plan to pre-approve the power wheelchair and components. You say that the medical records provided will show proof of medical necessity. The Plan denied your request.
The Plan says that the request for a group 3 multiple power option power wheelchair does not meet medical necessity criteria. All associated accessories cannot be approved without an approved base chair and therefore also not covered at this time.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a group 3 power wheelchair and components. Our Medical Director states the documentation does not support that the coverage criteria for a group 3 power wheelchair with power functions and expandable electronics though a joystick were met in this case. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for a group 3 power wheelchair and components. 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 power wheelchair and components have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) and components (E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, and E2603) for the enrollee.