Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Acute Inpatient Rehab stay from June 21, 
2021 to July 15, 2021. 
 
You asked the Plan to waive the copayment for Acute Inpatient Rehab stay. You say that you are requesting 
reconsideration of applied cost share. The Plan denied your request. The Plan says the copayment you are being 
charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment per day (up to five days) for Acute Inpatient Rehab stay.  
 
The enrollee has been asked to pay a $200 copayment per day (up to five days) for Acute Inpatient Rehab stay. 
Acute Inpatient Rehab stay falls within the Inpatient hospital care benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for Acute Inpatient Rehab stay from June 21, 2021 to July 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the domiciliary or rest home visit for the evaluation and management of 
an established patient (99336) rendered by the out-of-network (OON) provider on January 12, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of 
network provider, without prior authorization or a primary care physician (PCP) referral. 
 
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. Additionally, a Point of Service benefit is offered to enrollees to 
receive care from an out-of-network provider. 
 
The Plan contract indicates that there is a Point of Service benefit offered to enrollees to receive care from an 
out of network provider. The Plan contract states that a referral is not required when covered services are 
rendered by an out-of-network provider under the Point of Service option. The contract additionally indicates 
that services not covered by an out-of-network provider will require a referral and some services provided 
require an authorization as well. However, the Evidence of Coverage (EOC) contract does not clearly disclose 
what services are covered by the Point of Service Benefit; nor which services require prior authorization; 
hence, the member would not be able to decipher which services would require a referral or prior authorization 
if an out-of-network provider is utilized. As such, we find that the denial issued for a lack of a referral or prior 
authorization is not supported. Therefore, we decided that the Plan has to pay for the domiciliary or rest home 
visit for the evaluation and management of an established patient (99336) rendered by the out-of-network 
(OON) provider on January 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F5 gene testing services. 
 
You asked the Plan to pre-approve the F5 gene testing services. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says there is not enough proof that this test is medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the Factor V Leiden (FVL) 
variant in the F5 genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular 
risk assessment, are non-covered except for pregnant patients. 
 
We looked at the file and Medicare rules. In this case, you are not pregnant. Based on this information, we 
decided that Medicare rules for coverage of the F5 gene testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the F5 gene testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from 
August 4, 2021, to December 6, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $25 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $125 copayment for five specialist office visits ($25 x 5 = $125). 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 specialist office visits provided from August 4, 2021, to December 6, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer-assisted orthopedic procedure (0055T). 
 
You asked the Plan to pre-approve the computer-assisted orthopedic procedure (0055T). You say that your 
doctor feels strongly that you need to have knee replacement surgery via MAKOplasty as it reduces risk for 
error and is more precise. You say that the MAKOplasty offers faster relief and had a 9 times lower failure rate 
2 years post-surgery than that of manual knee replacements. The Plan denied your request. The Plan says the 
knee arthroplasty (27447) has been approved and the computer-assisted orthopedic procedure (0055T) remains 
denied as medical necessity has not been established for this procedure. 
 
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 computer-assisted orthopedic 
procedure (0055T). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that current evidence-based medical 
literature does not support the routine use of computer-assisted navigated total knee arthroplasty over 
conventional total knee arthroplasty. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception.  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 computer-assisted orthopedic procedure (0055T) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the computer-assisted orthopedic procedure 
(0055T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing laboratory services (80321, 80323, 80324, 
80332, 80335, 80338, 80342, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 
80360, 80364, 80365, 80366, 80368, 80369, 80372, 80373, 80375) provided on November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like these codes reprocessed and 
approved for payment. The Plan denied your request. The Plan says these codes are not valid for payment 
under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CTP codes 80320  80377 are non-covered by 
Medicare.  
 
 
 We looked at the file and Medicare rules. 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 drug testing laboratory services (80321, 80323, 80324, 80332, 80335, 80338, 80342, 80345, 80346, 
80348, 80349, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80364, 80365, 80366, 80368, 80369, 
80372, 80373, 80375) provided on November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heart procedures 33418 and 93355 (Transesophageal 
echocardiogram with transcatheter mitral valve repair) and inpatient hospital care. 
 
You asked the Plan to pre-approve a transcatheter mitral valve repair (TMVR).. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services will be 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 mitral valve repair 
(TMVR). Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation is inadequate to confirm fulfillment of published CMS guidelines for TMVR. 
 
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 mitral valve repair (TMVR). have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the heart procedures 33418 and 93355 (Transesophageal 
echocardiogram with transcatheter mitral valve repair) and inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 22, 
2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. You say that this genetic testing was 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage 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 pay for the cardiovascular genetic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is whether the requested genetic testing was medically appropriate 
and necessary. The test is described as a genetic based cardiovascular risk factor screening test in which 
multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of 
pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a 
diagnostic test. There is no evidence to support its role in this patient clinical management. In summary, the 
requested testing is not considered reasonable or medically 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 cardiovascular genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the cardiovascular genetic testing provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for over 6 months and has failed over 6 months of conservative approaches to 
treatment. You say that you recommend this minimally invasive procedure when conservative treatment has 
failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The 
Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the standard lumbar 
laminectomy. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to 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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the assisted living facility will not take you back 
without proper physical therapy. You say that the hospital says you need to be at the skilled nursing facility 
before going home. The Plan denied your request. The Plan says the records do not show that you need daily 
skilled services that can only be provided on an inpatient basis in a skilled nursing facility. 
  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 services. Our reviewer says that 
you no longer qualify for SNF coverage. Our physician reviewer found that you do not have documented 
skilled nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. 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 is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Continued care in the long-term acute care hospital is appropriate (and 
endorsed by the health plan) until the enrollee is stable to transfer to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that the enrollee's pain is disabling, and 
they have tried and failed conservative treatment without relief. You say that the evidence supports the use of 
the Intracept procedure as the primary treatment for chronic low back pain and the denial should be overturned. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered. 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, and 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 the Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyvaso (J7686).  
You asked the Plan to pre-approve Tyvaso. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage under the enrollee's medical 
benefit for Tyvaso have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for this drug to be covered, the enrollees 
pulmonary hypertension must not be secondary to pulmonary venous hypertension (e.g., left sided atrial or 
ventricular disease, left sided valvular heart disease, etc.) or disorders of the respiratory system (e.g., chronic 
obstructive pulmonary disease, interstitial lung disease, obstructive sleep apnea or other sleep disordered 
breathing, alveolar hypoventilation disorders, etc. 
 
We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with pulmonary 
hypertension that is secondary to interstitial lung disease. Based on this information, we decided that Medicare 
rules for coverage of Tyvaso have not been met. Therefore, we decided that the Plan does not have to pre-
approve Tyvaso (J7686).  
 
Benefits for Tyvaso 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 vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. 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 the vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to 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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Onetouch Ultra test strips (A4253). 
 
You asked the Plan to pre-approve the Onetouch Ultra test strips. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 Onetouch Ultra test strips. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found there is no reason given 
why the patient needs this brand of meter and strips; she could be prescribed the plan's preferred brand of meter 
and strips and use this once daily. 
 
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 Onetouch Ultra test strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Onetouch Ultra test strips (A4253).