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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 28, 2021, to March 4, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a determination was made to remove the secondary diagnosis code, consistent with the 
documentation received. 
 
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 provided with DRG 193 (SIMPLE PNEUMONIA AND 
PLEURISY WITH MCC). 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 services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the review indicates that the documentation supported an admission for Pneumonia. Although 
the diagnosis of "Acute respiratory failure with hypoxemia" is documented in the history and physical, 
supporting documentation was not found within the medical record. Although the patient had oxygen 
saturations in the 80s reported, according to the medical records provided for review, the patient was 
maintained on low flow oxygen at 1-3L and room air during his hospital stay. The review has determined that 
the records did not support the assignment of secondary diagnosis code J96.01. The records do not support 
DRG 193 (SIMPLE PNEUMONIA AND PLEURISY WITH MCC) in this case.  
 
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 hospital services provided to the enrollee from February 28, 2021, to March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxinA) for the enrollee. 
 
You asked the Plan to pre-approve Botox. You say that the preoperative chemodenervation of the lateral 
abdominal wall muscles utilizing Botox will reduce the tension of the midline abdominal wall closure and also 
has shown to decrease the postoperative pain. The Plan denied your request. The Plan says that the enrollee's 
diagnosis is not listed as a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that Botox is 
not medically reasonable and necessary. The patient has an incisional hernia with associated pain, nausea, and 
constipation. A request was made for Botox for pre-operation preparation prior to ventral hernia repair. The 
enrollee's diagnosis is not listed as a covered diagnosis, either on an FDA-approved diagnosis list or in off-label 
exceptions. The approved compendia also do not show sufficient supportive evidence to justify coverage for 
this use of Botox. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of Botox. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (onabotulinumtoxinA) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient diagnostic lab services provided on August 20, 
2021 to October 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient diagnostic lab services. You say that you were never told that the 
provider was out-of-network. The Plan denied your request. The Plan says the services were provided out-of-
network and not approved in advance. 
 
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 outpatient diagnostic lab services provided on 
August 20, 2021 to October 28, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion interspinous device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertiflex Superion interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. The rationale stated evidence in the published peer-reviewed scientific literature 
is lacking; long-term safety and efficacy has not been established despite Food and Drug Administration (FDA) 
approvals for most of these devices. Overall, use of interspinous or interlaminar distraction devices (spacers) 
used as an alternative to spinal decompression show high failure and complication rates. Greater certainty 
about the net health benefit of these devices may be obtained when recently completed and moderately sized 
randomized controlled trial on decompression with and without the implants are published. The evidence at this time is insufficient to determine the effects of the technology on health outcome. Therefore, the enrollee does 
not meet criteria for the requested 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 Vertiflex Superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept device. 
 
You asked the Plan to pre-approve Intracept device. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for vertebrogenic low back pain. There were/are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. The documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
Intracept intraosseous nerve ablation at L4, L5, and S1 is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard testing. 
 
You asked the Plan to pre-approve the Cologuard testing. You say that the enrollee has had a positive fecal 
occult blood test and does not wish to have a colonoscopy. This testing should be allowed to evaluate the need 
for computed tomography (CT) imaging of the colon. The Plan denied your request. The Plan says the enrollee 
has had a positive occult blood test which means the criteria for this testing are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard screening is covered only for 
enrollees who are asymptomatic, meaning there have not been positive gFOBT tests. 
 
We looked at the file and Medicare rules. The documentation clearly indicates that the enrollee has had an 
abnormal gFOBT test. As such, he cannot be considered asymptomatic. Based on this information, we decided that Medicare rules for coverage of the Cologuard testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cologuard testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (CPT code K0822). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records do not show 
documentation as to your ability to safely maneuver a power wheelchair or your caregivers inability to push 
you in a manual wheelchair, nor documentation of an assessment of your homes ability to accommodate a 
power wheelchair, nor documentation that you or your caregivers can safely transfer you into and out of a 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer 
found the medical records provided there is documentation that you have a personal mobility deficit that 
impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is documentation that your mobility deficit cannot be 
helped by the use of a walker or cane but provided records do not clarify that your mobility deficit cannot be 
helped by the use of a manual wheelchair. Based on the medical records provided there is no documentation 
that you can safely operate a power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and 
including 300 pounds (CPT code K0822).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 28, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing therapy can be provided at a lower level of 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for right lower leg 
cellulitis. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that bone growth stimulators are covered only when 
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 the bone growth stimulator. Our 
reviewer says that the requested stimulator is not medically necessary. Our physician reviewer found detailed 
documentation was not provided regarding indications of a failed fusion. Additionally, there is limited 
published, large-scale, long-term, peer-reviewed literature that shows this request to be an effective or safe 
treatment for the noted pathology. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 10, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne genetic testing provided on February 9, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that FoundationOne Liquid CDx accurately and reproducibly detects the major types of genomic 
alterations as well as complex biomarkers, such as MSI, bTMB, and tumor fraction. The literature supports the 
validity and utility of using a well-validated cfDNA-based CGP assay in the therapeutic management of cancer 
patients. The requested testing is medically reasonable and 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 testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne genetic testing provided on February 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says you could be treated with a bi-level positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found while you may benefit 
from bi-level positive airway pressure (BiPAP) therapy during sleep, Medicare does not cover a home 
ventilator when used as a BiPAP device. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).