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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 24, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive any daily skilled services. 
 
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 SNF care. 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 24, 2021, to December 31, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Thermal destruction of intraosseous basivertebral nerve 
(code 64628). 
 
You asked the Plan to pre-approve Thermal destruction of intraosseous basivertebral nerve. You say that 
Thermal destruction of intraosseous basivertebral nerve is medically necessary. The Plan denied your request. 
The Plan says Thermal destruction of intraosseous basivertebral nerve 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 Thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that Thermal destruction of intraosseous basivertebral nerve is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept 
procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare 
guidelines consider this type of system unproven and not medically necessary. Large well-designed studies in 
the peer review scientific literature comparing the stand-alone use of the Intracept device to the established 
surgical decompression, are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Thermal destruction of intraosseous 
basivertebral nerve (code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this equipment is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is considered 
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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. 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. 
  
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube that is malfunctioning. She is medically 
stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her 
baseline. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) and advance care planning 
(99497) provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care and care planning. You say that it is the responsibility of 
the hospital to obtain prior authorization. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) and advance care 
planning (99497) provided on January 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability (L5848), an addition, endoskeletal knee-shin 
system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, 
stance flexion feature, adjustable (L5845) and an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856). 
 
You asked the Plan to pre-approve a prosthetic leg and all components. You say that the prosthetic leg and 
components are medically necessary. The Plan denied your request. The Plan says that the provider describes 
no activities that cannot be met with a K3 mechanical knee, as you have been using. The described activity 
needs can be met with a mechanical knee. Notes do not show why a mechanical knee will not meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a prosthetic leg and all components. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found clinical documentation with evaluation is clear about the reason for 
recurrent falls as you frequently ambulate on variable surfaces with variable cadences and have a good lower 
limb strength. 
 
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 prosthetic leg and all components have been met. Therefore, we decided that 
the Plan has to pre-approve an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848), an addition, endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).  
 
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: Favorable

 
We decided that the Plan has to pay for molecular pathology services provided to the enrollee on September 14, 
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 that Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. 
 
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 denied these services based on the idea that panel testing must be 
reported with one code. The plan is claiming that Current Procedural Terminology (CPT) 81479 - the code at 
issue in this case - was billed on one claim form, and multiple other codes were billed on a separate claim form. 
The other claim form with the other billed codes was not provided by the plan for review in this case, so their 
denial cannot be verified. Therefore, we decided that the Plan has to pay for molecular pathology services 
provided to the enrollee on September 14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92004, 92250) and post-cataract-
surgery eyeglasses (V2020, V2300) provided on March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network vision care. You say that these services were medically necessary 
following your cataract surgery and should be covered under your medical benefit. The Plan denied your 
request. The Plan says out-of-network care is only covered in certain limited circumstances. The requested 
services were not urgent or emergent and could have been received 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 the medical eye exam (92004, 92250) and post-cataract-surgery eyeglasses (V2020, V2300) provided on March 23, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment applied was 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 $350 
copayment for inpatient hospital care.  
 
You have been asked to pay a $350 copayment for an inpatient hospital stay. An inpatient hospital stay 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 
an inpatient hospital stay provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair, fixed full-length arms, swing 
away detachable footrest (E1250). 
 
You asked the Plan to pre-approve a wheelchair. You say that please allow the enrollee to be able to have a 
wheelchair for his mobility to move around his home and provide protection from falling and allowing him to 
do daily living activities. The Plan denied your request. The Plan says a determination of medical necessity 
cannot be made as there is insufficient supporting clinical information to support current need. 
 
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 a wheelchair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted records do not indicate the enrollee is unable to perform mobility associated 
ADLs and if a wheelchair is needed there is no evidence that he is unable to use a standard wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair, fixed full-length arms, swing away detachable footrest (E1250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this device is considered 
experimental/investigational for the enrollee's condition. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, 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. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 admission. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 5, 2022 forward and could have been treated in a lesser restrictive 
setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. The enrollee was being cooperative and compliant 
while not showing any acute threats to safety. 
 
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 admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on March 14, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you feel this should be covered. You also say that you 
would like a list of approved providers for the second vaccine. The Plan denied your request. The Plan says the 
shingles vaccination is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that vaccinations or inoculations are excluded as 
immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or 
condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, 
or immune globulin. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vaccine have not been met. Specifically, the shingles vaccine is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on March 
14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing panel provided on 
February 21, 2022. 
 
You asked the Plan to pay for the Genesight Psychotropic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is not sufficient 
evidence to support payment for this testing.  
The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as Geneight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Based on this 
information, we decided that Medicare rules for coverage of the Genesight Psychotropic testing panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic testing 
panel provided on February 21, 2022.