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

 
We decided that the Plan does not have to pay for FoundationOne Liquid CDx testing (0239U) provided on 
March 11, 2022. 
 
You asked the Plan to pay for FoundationOne Liquid CDx testing. You say that this test was medically 
necessary and reasonable. The Plan denied your request. The Plan says this test is not medically necessary, as 
the enrollee has already been approved for FoundationOne CDx solid tumor testing and the Liquid CDx test 
was redundant in this case. 
 
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 FoundationOne Liquid CDx testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee previously had FoundationOne CDx testing for the same tumor. Repeat testing is not supported as medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FoundationOne Liquid CDx testing have not been met. Therefore, we decided 
that the Plan does not have to pay for FoundationOne Liquid CDx testing (0239U) provided on March 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the clinical documentation shows you do not have an IRF compliant diagnosis 
and functional impairments with the evaluating therapists recommended intense therapy but there are no active 
medical comorbidities specified that would require close medical supervision on an inpatient basis 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the medical 
records provided do not indicate that the enrollee meets the diagnostic criteria of both AD and FTD. The Plan 
also says there is no indication that the exam is being requested in the context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
 
 
 
 
 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 PET scan. Our reviewer says that the 
enrollee does not meet the criteria for coverage for a PET scan. Our physician reviewer found there has been a 
cognitive decline noted for at least 6 months. Our reviewer found based on the notes provided for review, there 
is only suspicion for Alzheimer's (with differential diagnoses for mild cognitive impairment). There was no 
mention of FTD within the records provided for review. It cannot be determined that the enrollee meets 
diagnostic criteria for AD either at this time. Our physician reviewer also found that in as much, this 
requirement of the National Coverage Determination (NCD) has 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried an oral bisphosphonate and zoledronic acid. 
 
 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 Prolia. Our physician reviewer found 
that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new 
start as defined by Medicare rules. The Plan requires a trial of an oral bisphosphonate and zoledronic acid 
before they will approve the requested drug. The provided records do not indicate that the enrollee has tried and 
failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee requires minimal assistance for dressing, bathing, and toileting. The 
enrollee has had a functional decline from her baseline level of function and would likely benefit from  
 occupational and physical therapy, but she does not require the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
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 IRF admission and services.
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. The Plan denied your request. The Plan says the medical records 
submitted do not establish that the admission to an IRF is reasonable and 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Our physician reviewer 
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with a StimQ peripheral nerve stimulator 
(PNS) device (64555). 
 
You asked the Plan to pre-approve a StimQ PNS device. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 
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 a StimQ PNS device. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested device is considered experimental/investigational. 
 
 
  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 StimQ PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with a StimQ peripheral nerve stimulator (PNS) device (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that you need the hearing aids, and the closest 
network provider is 2 hours away. You say that you have no choice but to go to a nearby provider. The Plan 
denied your request. The Plan says hearing aids from a non-plan provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through a plan-provider.  
 
We looked at the file and the Plan's rules. The case file shows that you are requesting coverage for hearing aids 
from a non-plan provider. Based on this information, we decided that the Plan's rules for coverage of hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga 10MG tablets. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Farxiga is a self-administered drug and the medication does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga 10MG tablets.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97530, 97535, 97112 and 97110) provided 
from April 18, 2022, to May 18, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary and were 
reported correctly. The Plan denied your request. The Plan says these services should be resubmitted with the 
KX modifier in order to be processed for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the KX modifier should 
be used as a confirmation that services are medically necessary after the beneficiary has exceeded the KX 
modifier threshold of incurred expenses. If a claim is submitted without KX modifiers and the cap is exceeded, 
those services will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the record shows that the enrollee in question has 
exceeded the KX modifier threshold of incurred expenses, but the KX modifier was not used on the 
claims/services at issue. Therefore, we decided that the Plan does not have to pay for therapy services (97530, 
97535, 97112 and 97110) provided from April 18, 2022, to May 18, 2022.
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 was admitted for respiratory failure and bradycardia. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided by an out-of-network provider on May 17, 
2022. 
 
You asked the Plan to pay for dental services. You say that you believe you should receive more 
reimbursement. The Plan denied your request. The Plan says that these services have been processed and paid 
correctly. 
 
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 failed to provide a 2022 Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for dental services provided by an out-of-network provider on May 17, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for IRF care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show they have 
not had previous ablation or MBB injections at the L4-S1 levels. 
 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 service. Our physician reviewer 
found there is no documentation of diagnostic blocks at the requested levels. Therefore, the request is deemed 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636).