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

 
We decided that the Plan does not have to pay for PGx testing provided to the enrollee on May 11, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that comprehensive panel for genotyping of genetic variations that may be linked to reduced/enhanced 
effect or severe side effects of drugs metabolized remains unproven as a screening tool. The clinical value and effectiveness of comprehensive pharmacogenetic testing have not been demonstrated in the peer reviewed 
literature. the review has determined that the requested PGx testing is not medically reasonable or necessary 
according to the coverage criteria established in the guidelines. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for PGx testing provided to the enrollee on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve a CGM. You say that the CGM is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee is not on insulin and 
there is no mention in the clinical documentation of how often the enrollee checks their blood sugars. Based on 
this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine additional immunohistochemistry strains and a 
targeted genomic sequence panel (51 or greater genes) provided to the enrollee on December 9, 2021. 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the additional testing is excessive and unproven. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the enrollee did not need the other nine stains. The enrollee did not 
need the genomic sequence panel as the test does not have clinical validity or utility. The testing did not get 
used in the medical management of the enrollee. 
 
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 pre-approve nine additional immunohistochemistry strains and a targeted genomic sequence panel (51 
or greater genes) provided to the enrollee on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service July 26, 
2021. 
 
You asked the Plan to pay for procedure code 20936. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20936 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate level of 
care for the enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
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 be administered safely at the current facility until more 
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. Transfer to LTACH is not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 4, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services received are not a covered benefit when provided by an OON 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 office visit provided on February 4, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis provided on March 31, 2022. 
 You asked the Plan to pay for the billed services. You say that the claim meets the coverage criteria. The Plan 
denied your request. The Plan says the records do not support payment for this service. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the orthosis provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that total electric hospital beds are statutorily not covered. 
 
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 a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery and physician services provided from December 
16, 2021, to December 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical documentation supports the 
charges. The Plan denied your request. The Plan says the services are bundled as part of the global surgical fee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. The services at issue are included in the global surgery package for the 
procedure that was rendered on November 16, 2021, which has a 90-day global surgery period. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgery and physician services provided from 
December 16, 2021, to December 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomographic (CT) colonography, diagnostic, 
(74261) provided on April 8, 2022. 
 
You asked the Plan to pay for the CT. You say that the enrollee meets the policy exception criteria due to their 
advanced age with increased sedation risk. You also say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for the CT. Our reviewer says that the requested 
CT is not medically necessary. Our physician reviewer found the provided documentation does not include a 
digital rectal examination from their previous appointment. The reviewer found that the CT colonoscopy was 
elected to minimize risk. The documentation does not include a complete exam and indicates that a 
sigmoidoscopy was recommended. The reviewer also found that the documentation does not indicate additional 
contraindication to direct colonoscopy outside of the enrollees age. Therefore, the reviewer found that the 
requested CT is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to 
pay for computed tomographic (CT) colonography, diagnostic, (74261) provided on April 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. The Plan denied your request. The Plan 
says this request is not medically necessary because the records do not show that the enrollee has any of the 
covered indications for stress testing with cardiac imaging. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patient experiencing new, recurrent, or worsening cardiac symptoms. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a myocardial perfusion imaging. Our 
reviewer says that there is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing in this enrollees clinical management. Our physician reviewer found the enrollee has a history of 
exertional dyspnea. The enrollees pre-test probability for an abnormal test is low and there is no 
documentation that the electrocardiogram shows an uninterpretable pattern. Our reviewer also found that there 
is no evidence provided that would support the need for radionuclide stress 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 a myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and 
multiple accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME). Our physician reviewer 
found the documentation indicates the enrollee has a mobility deficit that impairs MRADLs in the home and cannot be overcome with a manual wheelchair, walker, or cane due to weakness. While the enrollee may be 
able to safely use the requested wheelchair the documentation does not reveal that the requested chair with 
multiple power options is medically necessary. The request for a Group 3 power wheelchair with multiple 
accessories exceed the enrollee's medical need. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (CPT code K0861) and multiple accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you were admitted with complications from cardiomyopathy and have a prolonged 
hospital course. The record indicates that you still require acute care services before transitioning to a lower 
level of care. You continue to receive acute care services and these have not been denied. The medical record 
does not indicate that you require services that you are not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model without 
calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic 
compressor (E0667) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says they have in-network providers that you can receive care from. 
 
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 
pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor (E0667) to be provided by an out-of-
network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the head 
without contrast (70544). 
 
You asked the Plan to pre-approve MRA of the head. You say that submitted medical records show necessity. 
The Plan denied your request. The Plan says the request for an MRA of the brain is not approved. Despite 
multiple requests on initial review and appeal, no records to substantiate the request were received for review. 
 
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 MRA of the head. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee is not suspected of 
having a condition for which surgery is anticipated and may be found to be appropriate based on the MRA. 
There was nothing on exam or the enrollee's history to suggest the presence of a condition for which surgery 
may be indicated. In as much, this request would not meet Medicare requirements for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRA of the head have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance angiography (MRA) of the head without contrast (70544).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you do not feel that this should be denied. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not have an indication for Ketruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Keytruda. Our physician reviewer found Keytruda is not Food 
& Drug Administration (FDA) approved for the enrollees condition. The requested use is not supported by one 
of the major drug compendia or by clinical research appearing 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found provided records do not document nonunion of the bone fracture with 
serial radiographs confirming that fracture healing has ceased for 3 or more months. The provided records 
report that a follow-up x-ray of the foot at 5 weeks showed good interval bone healing. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).