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

 
We decided that the Plan does not have to pay for the laboratory services coded as (81376) provided May 12, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that the physician determined the test was 
medically necessary in determining the best course of treatment and forwarded the patients specimen to us for 
testing. The Plan denied your request. The Plan says this service does not meet the coverage requirements in 
the applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
In this case, the CPT Code Manual definition of code 81376 is HLA Class II typing, low resolution (e.g., 
antigen equivalents); one locus (e.g., HLA - DRB1, - DRB3/4/5, - DQB1, - DQA1, - DPB1, or - DPA1), each.   
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there was no specific clinical rationale provide for the laboratory testing. 
The review has determined that the items/services at issue in this case were 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as (81376) provided May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve diabetic supplies. You say that this should be covered as medically 
necessary. The Plan denied your request. The Plan says the patient does not meet the criteria listed in the EOC. 
 
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 
diabetic supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on December 07, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on December 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tempus xT gene analysis provided on January 26, 
2022. 
 
You asked the Plan to pre-approve the Tempus xT gene analysis. You say that this was medically necessary 
testing. The Plan denied your request. The Plan says your request is not medically necessary because your 
records show you do not have advanced disease or plan to tailor treatment based on the testing results. 
 
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 Tempus xT gene analysis. Our 
reviewer says that the testing provided is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the male enrollee has a mucinous adenocarcinoma of the lung. The record sent by the 
provider indicates that he underwent a fine needle biopsy of a lung mass and a pathology report dated December 23, 2021, with a differential diagnosis that included mucinous metaplasia and well differentiated 
adenocarcinoma. A supplemental pathology report dated January 4, 2022, diagnosed mucinous 
adenocarcinoma of the lung. Included records do not indicate recurrent or advanced disease, or plan to seek 
treatment based on the test results. The review has determined that the items/services at issue in this case are 
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 Tempus xT gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Tempus xT gene analysis provided on January 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee should be covered for SNF services 
beyond March 19, 2023. The Plan denied your request. The Plan says the request 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that as of the last covered day, there were no skilled nursing needs or skilled rehab 
needs on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. 
The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, the the enrollee did not require any skilled services on an inpatient basis, at a skilled level of 
care as of 3/19/23. The enrollee did not have any parental medications, complex wound care or nutrition given 
via a feeding tube.  The members function was at or near her prior level of function and she could be 
discharged to a lower level of care for further services. As of 3/19/23, the enrollee required custodial services.  
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from October 17, 2022, to 
October 20, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were transported and admitted to the 
hospital due to a heart attack. The Plan denied your request. The Plan says self-administered drugs are not 
covered under Medicare Part B. 
 
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 pay for self-administered drugs provided 
from October 17, 2022, to October 20, 2022.  
 Benefits for self-administered drugs 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the hospital. 
The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis.  The enrollee 
medically stable and can receive further rehab services at a lower level of care. Although further rehab services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. Additionally, the enrollee does not have any 
frequent (more than once a day) parental medication; daily complex wound care or nutrition given via a feeding 
tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The 
enrollee's physical function is at or near the baseline, and the enrollee can receive the services at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 LTACH is not medically necessary. 
The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
are being met in the current hospital facility. 
 
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 the enrollee was hospitalized for infection status post right above knee amputation 
(AKA) and renal calculi with hydronephrosis. The enrollee does not require extensive or complex wound care 
management by skilled nursing of at least six and a half hours per day. Additionally, the wound care does not 
require daily intervention by a physician. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 
 
 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 a group 3 power wheelchair and accessories (K0861, 
E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620). 
 
You asked the Plan to pre-approve the services. You say that that the enrollee is unable to complete MRADLs 
without this equipment. The Plan denied your request. The Plan says the request for power wheelchair cannot 
be covered. 
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the enrollee 
has caregivers and despite her chronic incontinence and neurological impairment does not have skin 
breakdown. There is no quantification of increased risk with her current condition. As noted above she does not 
have other qualifying conditions for tilt or recline power drives. She has adequate upper body strength to 
manage standard power switches. 
 
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 a group 3 power wheelchair and accessories (K0861, E0955, E1007, E1012, E1028, 
E2311, E2313, E2361, E2377, E2607, E2620).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a parathyroidectomy procedure provided on 
November 01, 2022. 
 
You asked the Plan to waive the copayment for a parathyroidectomy procedure. You say that you were not 
aware that there was a copayment for this service. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $275 
copayment for in-network outpatient hospital visits. 
 
You have been asked to pay a $275 copayment for a parathyroidectomy procedure. This item/service falls 
within the in-network outpatient hospital 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 parathyroidectomy procedure provided on November 01, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 24 physical therapy sessions (beyond the 
12 approved sessions). 
 
You asked the Plan to pre-approve the therapy services. You say that the requested therapy should be approved 
in full. The Plan denied your request. The Plan says you are just starting therapy. The Plan states that it is 
necessary to see how you are doing after the 12 approved sessions to see if more therapy is needed at that time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has major functional loss after brain trauma. The record 
only contains a physical therapy evaluation. Continued therapy authorization depends upon response to therapy 
or need for continued maintenance. The record at present does not indicate how much therapy the enrollee will 
require. It is routine to re-assess after 2 weeks of therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 24 physical therapy sessions (beyond the 12 approved sessions).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more therapy days to recover 
from hip surgery. The Plan denied your request. The Plan says the enrollee does not require skilled nursing care 
or therapy in a skilled nursing setting given their conditions and lack of progress with therapies. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, there is 
no documentation supporting the need for daily skilled therapy. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 is in need of cognitive help and cannot 
walk more than a few steps without the risk of falling. The Plan denied your request. The Plan says IRF 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require intensive rehabilitation. The enrollee is functioning 
at home care level, but requires supervision for transfer and walking 220 feet.  
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 the special contact lens fitting on June 29, 2022. 
 
You asked the Plan to pay for the special contact lens fitting. You say that the contact lens fitting was done 
following your cataract surgery and this should be a covered benefit. The Plan denied your request. The Plan 
says that the service is not a covered benefit. 
 
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 did not show that the contact lens fitting was not done after cataract 
surgery. Therefore, we decided that the Plan has to pay for the special contact lens fitting on June 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says 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 genicular nerve blocks. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested services are considered experimental/investigational and are the subject 
of ongoing clinical trials. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks (64454).