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

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided 
December 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDX meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 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 FoundationOne CDx (F1CDx) test (0037U) provided December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 12, 2021, through July 
14, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that sepsis was sequenced first as present 
upon admission and urinary tract infection as secondary as it was the infection that led to sepsis. You say that 
the documentation in the medical record clearly supports the diagnosis of sepsis due to Escherichia coli and 
payment of the entire claim should be approved. The Plan denied your request. The Plan says the diagnosis 
code for sepsis due to Escherichia coli is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with principal diagnosis code A41.51, defined as sepsis due to 
Escherichia coli (E. coli). 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 inpatient services 
at DRG 871. Our reviewer says that the documentation does not support the diagnosis code A41.51. Our 
physician reviewer found the enrollee was admitted for the management of suspected urinary tract infection 
and the urine culture returned with growth of Escherichia coli. The enrollee did not require the intensive care 
unit and did not exhibit evidence of life-threatening organ dysfunction related to a dysregulated immune 
response to infection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from July 12, 2021, through July 14, 2021, at DRG 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain an 
authorization and the service rendered was medically necessary. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was 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 home health visit provided on July 7, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on January 24, 2022. 
 
You asked the Plan to pay for the refraction. You say that the provider is in-network, and the tests were 
medically necessary. The Plan denied your request. The Plan says eye refractions are only covered if performed 
by a participating provider with a routine screening. 
  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. The Plan covers a refraction when performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Specifically, the refraction was not performed with a routine eye 
exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on January 24, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), soft tissue neck (70491). 
 
You asked the Plan to pre-approve a CT scan. You say that a neck CT is necessary for further evaluation of the 
enrollee. The Plan denied your request. The Plan says the requested neck CT is not medically necessary. 
 
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 pre-approve a CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the provided documentation did 
not describe the lymph node as suspicious in texture (lack of mobility, rough, etc.). The reviewer found that 
there was no record of having ordered a simple x-ray which would be the next appropriate testing step if the 
thought was that it was not a reactive lymph node. Therefore, the request for CT will be considered not 
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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT), soft tissue neck (70491).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on February 4, 2022. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided medical records 
to support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is included in another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) 
provided on February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint with placement of 
transfixing device (27279). 
 
You asked the Plan to pre-approve an arthrodesis of the sacroiliac joint. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested services are 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 an arthrodesis of the sacroiliac joint. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no documented sacroiliac joint instability, fracture, or lesion. 
Sacroiliac fusion for degenerative back pain is experimental; additionally, the SILO device for sacroiliac fusion 
is experimental. 
 
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 arthrodesis of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint with placement of transfixing 
device (27279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482, 80307) provided on January 24, 2022. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not ordered by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician. 
 
We looked at the file and Medicare rules. The order included in the file is for a different enrollee. Based on this 
information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing (G0482, 80307) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went to an urgent care clinic 
and should not have a copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $35 
copayment for services obtained from a specialist.  
 
The file shows that the visit was billed as a regular office visit, not as urgent care. Therefore, you have been 
asked to pay a $35 copayment for the office visit. The office visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 2, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this charge should be covered. 
The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay $275 
copayment for surgery performed in an outpatient hospital setting.  
 
You have been asked to pay $275 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
February 2, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Bortezomib injection (J9041) provided on September 29, 2021. 
 
You asked the Plan to pay for the Bortezomib injection. The Plan denied your request. The Plan says that 
experimental or investigational services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Bortezomib injection. Our reviewer says 
that the service is reasonable and medically necessary. Our physician reviewer found Bortezomib is Food and 
Drug Administration (FDA) approved for the treatment of multiple myeloma. It is standard of care in 
combination with Lenalidomide and Dexamethasone as maintenance therapy after stem cell transplant or as 
monotherapy. Our reviewer also found that this is how it is being used for this patient status post autologous 
stem cell transplant during March 2020. 
 
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 Bortezomib injection have been met. Therefore, we decided that the Plan 
has to pay for the Bortezomib injection (J9041) provided on September 29, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. The Plan denied your request. The Plan says it 
was not clear that you have seen a psychiatrist and have been recently evaluated or treated for anxiety, 
depression, or trauma. The Plan also says that you do not meet all of the rules for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that Neuropsychological Testing is testing which is 
intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or 
indirectly on the brain. 
 
 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 neuropsychological testing. Our 
reviewer says that you do not meet the criteria for coverage for neuropsychological testing. Our physician 
reviewer found you are not showing severity of symptoms that would warrant this type of diagnostic treatment 
and therefore it is not medically necessary or reasonable. Our reviewer also found that it is unclear what 
questions are to be answered by neuropsychological testing and it is unclear what tests are to be performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet injection under sedation. 
 
You asked the Plan to pre-approve a lumbar facet injection under sedation. You say that a lumbar facet 
injection under sedation is medically necessary. The Plan denied your request. The Plan says a lumbar facet 
injection under sedation does not meet coverage under Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not reasonable and 
necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care (MAC) is 
routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely 
reimbursable 
 
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 lumbar facet injection under sedation. 
Our reviewer says that a lumbar facet injection under sedation is not medically necessary. Our physician 
reviewer found that according to the Medicare coverage criteria, general anesthesia is not considered 
reasonable and necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia 
care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given on redetermination for reimbursement for 
unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical 
record. In this case, there is no documentation of unique circumstances of medical necessity. In addition, the 
office note received did not report a trial of oral anxiolytics prior to the procedure. The requested MAC is 
based on patient request and preference. There is no documentation provided that this procedure, which can be 
performed safely without conscious sedation or MAC, cannot be done.  The review has determined that MAC 
is not medically necessary per Medicare LCD policy. 
 
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 lumbar facet injection under sedation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar facet injection under sedation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that the requested device is 
medically reasonable and necessary. The Plan denied your request. The Plan says the requested device 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 the MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Motion G device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non emergent and prior authorization was not obtained. 
 
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 psychotherapy services (90837) provided on 
February 9, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits in your home. 
 
You asked the Plan to pre-approve PT visits in your home. You say that you need more physical therapy visits 
to help you improve. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 PT visits in your home. Our reviewer 
says that the requested PT visits in your home are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that you have home health skilled therapy needs. Therefore, the 
reviewer found that the requested home health PT visits are not 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 PT visits in your home have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) visits in your home.