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

 
We decided that the Plan does not have to pay for FoundationOne Heme (F1Heme) testing provided on 
September 9, 2021, billed with code 81455. 
 
You asked the Plan to pay for the F1Heme testing as billed. You say that this is a medically necessary test for 
the enrollee's condition. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a 
limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 
81450 may be covered by Medicare.   
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for FoundationOne Heme (F1Heme) testing provided on September 9, 2021, billed with code 81455.
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation wireless pulmonary artery 
pressure sensor (33289 and C2624) 
 
You asked the Plan to pre-approve a transcatheter implantation wireless pulmonary artery pressure sensor. You 
say that the service is medically necessary. The Plan denied your request. The Plan says the service is 
experimental. 
 
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 transcatheter implantation wireless 
pulmonary artery pressure sensor. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found more information is needed on the safety 
and efficacy of this service for the members diagnosis. 
 
 
 
 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 transcatheter implantation wireless pulmonary artery pressure sensor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter implantation 
wireless pulmonary artery pressure sensor (33289 and C2624)
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 does not meet 
criteria. 
 
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 at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The enrollee will not 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee would benefit from 
viscosupplementation for both knees to improve her mobility and allow more joint movement as well as muscle 
strengthening. The Plan denied your request. The Plan says the records do not show that the enrollee has had a 
poor response to other drugs first. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that 
Orthovisc is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has not trialed 2 preferred viscosupplemental treatments such as Euflexxa, Supartz FX, Durolane, and/or 
Gelsyn-3. Step therapy, as outlined by the plan, requires that these be trialed first. Our reviewer found that the 
documentation does not outline contraindications or reasons these medications were not considered or that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our 
physician reviewer also found that without the support of the documentation, Orthovisc is not approved as step 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies 
(S1015 and S8301) provided on June 4, 2021. 
 
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like 
reconsideration because these items were provided at your expense. The Plan denied your request. The Plan 
says CPT codes S1015 and S8301 have a status indicator of I. 
 
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 CPT codes S1015 and S8301 are not supported in the medical record. Specifically, CPT codes 
S1015 and S8301 have a status indicator of I. This means that these codes are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) 
tubing and infection control supplies (S1015 and S8301) provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) and abutment 
supported porcelain/ceramic crowns (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that the enrollee was approved for implants and the oral surgeon already placed the implants. 
You also say that the enrollee needs the abutment and crown in order to have better oral health. The Plan 
denied your request. The Plan says these services are not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutments (D6057) and abutment supported porcelain/ceramic crowns (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Umano Ook Snow total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve an Umano Ook Snow 
total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (69209) provided on February 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
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 payment for CPT code 69209 is not supported in the medical record. Specifically, the code 69209 
has a PCTC indicator or 5. This means that payment cannot be made for services provided to hospital inpatients 
or patients in the outpatient department of the hospital. The records in this case show that the services were 
provided in the emergency room, as indicated by place of service 23. 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 services (69209) provided on February 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on July 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facility's 
responsibility to get authorizations for their patients. You also say that you did not know that the facility failed 
to get pre-authorization for this patient, so you treated this patient anyway. The Plan denied your request. The 
Plan says an authorization was not obtained prior to the services being rendered and the provider is not 
participating with the member's Plan. The Plan also says that it was also determined that the services were 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 domiciliary or rest home visit (99336) provided 
on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nplate (J2796). 
 
You asked the Plan to pre-approve Nplate. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has not been prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Nplate. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Nplate is not FDA-approved for the enrollees diagnosis. Neither is the use supported by one 
of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Nplate (J2796).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve these services. You say that the Plan network does not have a neurosurgeon. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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. The Plan has approved the referral to the out-of-network provider 
under your Point of Service (POS) benefit. Therefore, we decided that the Plan does not have to pre-approve a 
referral to an out-of-network neurosurgeon.
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 does not meet 
criteria. 
 
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's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that the enrollee requires this therapy on an intensive 
IRF level. 
 
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: Favorable

 
We decided that the Plan has to pre-approve an inpatient psychiatric admission from March 7, 2022 forward. 
 
You asked the Plan to pre-approve the inpatient psychiatric admission. The Plan denied your request. The Plan 
says that this request is not medically necessary because the records received show that the enrollee's condition 
has improved, and they are no longer a threat to themself or others. 
 
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 the inpatient psychiatric admission. Our 
reviewer says that the inpatient psychiatric admission is medically reasonable and necessary for the enrollee. 
Our physician reviewer found it is expected this enrollee will improve in a reasonable period of time as 
although she did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations, this 
patient was labile, disorganized, intrusive, disheveled and isolating to her room. This patient did show 
abnormal behaviors and symptoms which would require acute treatment. It does appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care. Active treatment was taking place and the services were reasonably expected to improve the patients 
condition or are for the purpose of diagnosis. The record does not include an individualized treatment plan, but 
the entire record is not present. The services were supervised and evaluated by a physician. The Plans denial 
of continued inpatient psychiatric services is inappropriate. 
 
 
  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 inpatient psychiatric admission have been met. Therefore, we decided that 
the Plan has to pre-approve an inpatient psychiatric admission from March 7, 2022 forward.  
 
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 contact lens fitting (92310) provided on October 18, 
2021. 
 You asked the Plan to pay for contact lens fitting. You say that you have not had to pay for contacts with your 
plan before. The Plan denied your request. The Plan says the contact lens fitting fee is not covered by your 
benefit and is your responsibility. 
 
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.  
 
Though the Plan offers a vision benefit in excess of Medicare coverage, contact lens fitting fees are not among 
those services covered by this benefit. Therefore, we decided that the Plan does not have to pay for the contact 
lens fitting (92310) provided on October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on February 11, 
2021. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this service has been previously processed and 
paid. 
 
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 electrocardiogram (93010) 
provided on February 11, 2021. have been met. Specifically, the record indicates that the Plan previously 
processed and paid CPT code 93010. The documentation submitted does not indicate that more than one unit of 
CPT code 93010 was provided on the billed date of service. Therefore, we decided that the Plan does not have 
to pay for the electrocardiogram (93010) provided on February 11, 2021.