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

 
We decided that the Plan does not have to pay for genetic testing provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 genetic testing provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve a SNF stay. The Plan denied your request. The Plan says the enrollee does 
not need skilled therapy services 5 days a week, and the enrollee does not need daily skilled nursing care. The 
Plan also says that the enrollee can receive the care they need in another setting. 
 
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 a SNF stay. Our reviewer says that you 
do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a 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 a SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for inpatient hospital care provided 
from December 23, 2021, to December 27, 2021. 
 
You asked the Plan to waive or reduce the copayment for the inpatient care. You say that your wife had two 
heart attacks and her cost share was lower. 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 $225 per 
day for days 1-7 and $0 per day after day 7 for each inpatient admission.  
 
The file shows that you were in the hospital from December 23, 2021, to December 27, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $225 per day for the first 4 days of 
inpatient care. The total for your stay is $900 ($225 copayment x 4 days = $900). The inpatient care falls within 
the Inpatient Hospital Care 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 or reduce the copayment for 
inpatient hospital care provided from December 23, 2021, to December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart device (CPT code 0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart device. You say that the device is necessary. The Plan 
denied your request. The Plan says the Optimizer Smart device is considered unproven and is 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 the Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Optimizer Smart device is not necessary in this enrollee. 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 Optimizer Smart device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart device (CPT code 0408T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-electric hospital bed, with any type side rails, with 
mattress (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that you don't necessarily need the bed to adjust 
the upper part of your body, although it would be nice. What you need is a bed that you can adjust your legs as 
needed while you are laying down. The Plan denied your request. The Plan says the request is not medically 
necessary as the records show that the enrollee does not meet any of the criteria. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient:  
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per the clinical documentation provided, the enrollees condition of leg cramps does not require 
the positioning of the body in a way that is not feasible with an ordinary bed. The enrollee does not require 
frequent changes in body position. There is no need for immediate changes in body position. The enrollees 
condition of leg cramps does not require special attachments that require fixation to a bed. The enrollee has a 
diagnosis of leg cramps. There is no information provided regarding the cause of the enrollees leg cramps. 
Additionally, a traditional pillow has been used to elevate the legs of the enrollee and there is no indication that 
a proper wedge pillow was attempted to be used for her positioning needs. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve semi-electric hospital bed, with any type side rails, with mattress (E0260).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing services. 
 
You asked the Plan to pre-approve continued skilled nursing services. You say that it is very beneficial for you 
to stay in the skilled nursing facility longer. The Plan denied your request. The Plan says the records do not 
indicate that you require skilled nursing services in a SNF on a daily basis. 
 
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 continued skilled nursing services. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 continued skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy sessions. 
 
You asked the Plan to pre-approve additional occupational therapy sessions. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee's ability to do daily tasks has not 
significantly changed, and detail is lacking in the skills that require further treatment of the enrollee's condition 
by an occupational therapist. 
 
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 additional occupational therapy 
sessions. 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 there is no documentation that the 
specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver 
a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Based on the 
latest available records the enrollee "did not display motor planning deficits and had no difficulty maintaining 
grip on grab bar in bathroom" and "patient is resuming to PLOF." After the therapy already provided, treatment 
records do not support that the complexity of the enrollee's conditions are such that the skills of a professional 
therapist are required to achieve further improvement in the enrollee's symptoms or functional status. Further 
utilization of a home exercise program and/or assistance from facility staff appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional occupational therapy sessions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) additional occupational therapy sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee was diagnosed with painful pes 
planus with calloses of both feet in 2018. He was provided with custom orthoses from the podiatrist. His 
condition is unchanged. He still needs the inserts. Without them, it is painful to walk, and his quality of life is 
significantly reduced. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on October 9, 2021, to 
October 13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the criteria for an inpatient hospital admission has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record does show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on October 9, 2021, to October 13, 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 pay for the liver elastography (91200) provided on January 15, 2021. 
 
You asked the Plan to pay for the liver elastography. You say that you mailed this claim on January 11, 2022, 
and the Plan said they did not receive it until January 28, 2022, which is 17 days. You also say that you would 
like to appeal the denial of this claim due to the long delivery service time, for which you had no control over. 
The Plan denied your request. The Plan says this claim was received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the liver elastography was not filed until January 28, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the liver elastography (91200) provided on January 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity (73721). 
 
You asked the Plan to pre-approve an MRI of the lower extremity. The Plan denied your request. The Plan says 
an MRI at this time would not be medically reasonable. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower extremity. Our 
reviewer says that an MRI of the lower extremity is not reasonable and necessary. Our physician reviewer 
found the patient has left hip pain for which she was treated with physical therapy (PT) which helped her hip 
and leg pain, but it returned when PT was halted. An MRI of the left hip was requested. Our reviewer found 
that recent notes reveal she has not recently, in the past 3 months, tried restarting PT or home exercises, as 
before which had helped her significantly in the past. Also, there were no signs of a likely red flag diagnosis to 
justify MRI prior to restarting PT/exercises. Our physician reviewer also found that this request for MRI will 
be considered not medically necessary at this time. 
 
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 MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower extremity (73721).
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 meets medical necessity for IRF. The 
Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation therapy services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on September 3, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only considered for 
coverage when billed with CPT code 81479.  
 
We looked at the file and Medicare rules. Per A58192, Guardant360 testing must be billed with code 81479. 
The testing in this case was not billed with code 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant360 testing provided on September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pemetrexed Disodium for the enrollee. 
 
You asked the Plan to pre-approve Pemetrexed Disodium. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the requested drug would be deemed a routine cost.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Pemetrexed Disodium as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Pemetrexed Disodium for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Minuteman spacer is 
considered experimental in nature, as more research is needed to show it safety and efficacy. The services are 
therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Minuteman spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an astigmatism-correcting intraocular lens (A-C IOL). 
 
You asked the Plan to pre-approve the requested services. You say that you need a special lens or the cataracts 
would keep coming back. The Plan denied your request. The Plan says Medicare does not cover the extra cost 
for this lens. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
We looked at the file and the rules. While an A-C IOL may be appropriate for you, neither the Plan nor 
Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not 
have to pre-approve an astigmatism-correcting intraocular lens (A-C IOL).