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

 
We decided that the Plan does not have to pay for the Comprehensive pharmacogenomics (PGx) Panel, 32 
genes and the comprehensive cardio panel, 117 genes provided on September 22, 2022. 
 
You asked the Plan to pay for the comprehensive PGx panel and comprehensive cardio panel. You say that the 
testing was medically necessary to determine whether medicines the enrollee is taking are beneficial or could 
increase the risk toward an adverse drug reaction. The Plan denied your request. The Plan says there is no documentation to how the results will impact treatment. Also, the enrollee has a known past medical history of 
atherosclerotic heart disease. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing and hereditary 
cardiovascular disease testing may be covered when medically reasonable and necessary and the test results 
would directly impact the management of the patients treatment plan. 
 
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 comprehensive PGx panel and 
comprehensive cardio panel. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found that the test is described as a genetic based cardiovascular risk factor screening test in which 
multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of 
pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a 
diagnostic test. There is no evidence to support its role in this enrollees clinical management. In summary, the 
requested testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the comprehensive PGx panel and comprehensive cardio panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the Comprehensive pharmacogenomics 
(PGx) Panel, 32 genes and the comprehensive cardio panel, 117 genes provided on September 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's potential recovery can be 
met at a faster rate in an LTACH setting. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for admission to the 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. Our 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available. As an LTACH and an acute care hospital (ACH) are licensed to provide the same level of care, there 
is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until 
such time as no acute services are required. The enrollee can then be transferred/discharged to a lower level of 
care for any ongoing long term care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can render services that will 
improve the enrollee's condition and avoid unnecessary hospital readmissions. The Plan denied your request. 
The Plan says the requested LTACH care is not medically necessary. 
 
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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis.  
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy. You say if you are left 
without support, you will be unable to perform daily functions. The Plan denied your request. The Plan says 
you do not meet the Medicare criteria for admission to an IRF. 
 
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 your nursing, rehabilitation, and medical needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While you may benefit 
from physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity and 
alternate setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MILD procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says large population sufficiently powered randomized controlled trials that demonstrate 
long-term health outcome advantages are needed. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MILD procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric adjustable hospital bed. 
 
You asked the Plan to pre-approve an adjustable hospital bed. You say that a new bed was ordered for you due 
to your size. You need this bariatric sized bed; you keep falling out of your current bed. You have side rails to 
prevent a fall, but you are not able to roll over in your current bed. You are requesting reconsideration. The 
Plan denied your request. The Plan says you have multiple medical issues; however, you can ambulate out of 
bed with a steady gait and get in and out of bed safely without assistance. In addition, you can now use the 
bedside rails your family bought. It is also recommended that you remove some of the excess pillows in the bed 
to give you more room to prevent falling out of bed. As the adjustable bed is not medically necessary, it does 
not meet the "excluded services" criteria, the request for the adjustable bed has not been approved. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 adjustable hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have requested a 
bariatric bed to keep from falling out of bed. You do not require the bed to address other underlying medical 
issues or because you require frequent and urgent position changes. You do not meet NCD 280.7 criteria for 
approval.  
 
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 adjustable hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bariatric adjustable hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure System. 
 
You asked the Plan to pre-approve a CardioMEMS Heart Failure System. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS Heart Failure System. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
this enrollees clinical management. 
 
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 CardioMEMS Heart Failure System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CardioMEMS Heart Failure System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent urinary catheters (900 units for three 
months). 
 
You asked the Plan to pre-approve the additional units. You say that this is medically necessary. The Plan 
denied your request. The Plan says 200 units are allowed per month. 
 
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 additional units. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not show a need for a greater quantity than usual of A4351 (200 catheters 
per month).  200 catheters per month are more than adequate.  
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intermittent urinary catheters (900 units for three months).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the recorder. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by the health plan. 
 
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 recorder. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for an implantable loop recorder (ILR) is medically 
necessary. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for this monitor. In summary, there is insufficient documentation to support 
the medical necessity for insertion of this monitor in this patients clinical management. 
 
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 recorder have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007). 
 
You asked the Plan to pre-approve a wheelchair. You say that you are over 300 pounds and is unable to walk. 
You are waiting to have hip replacement surgery. The Plan denied your request. The Plan says the request for 
an extra heavy-duty wheelchair as 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 a wheelchair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation dated May 17, 2022, indicated that the enrollee uses a cane for 
mobility at home and difficulty with community mobility. The enrollee was noted to have lower extremity 
venous stasis, normal range of motion at the hip joint, and no focal neurological deficits. The enrollee is 
currently using a cane for mobility but is limited in terms of endurance and functional mobility. However, there is insufficient physical examination documentation, including lower and upper extremity strength and the 
weight of the enrollee, to determine if the requested heavy-duty wheelchair is appropriate. It also unclear if the 
enrollee can safely operate the requested manual wheelchair and if the home can accommodate it. Therefore, 
the heavy-duty wheelchair is 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extra heavy-duty wheelchair (K0007).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for this case, the need for IMRT is not justified based upon quantifiable dosimetric measures or a 
plausible rationale. American Society for Radiation Oncology (ASTRO) model policy emphasizes the need to 
support IMRT with dosimetry; this would be of particular importance for clinical scenarios for which IMRT is 
not considered standard. IMRT would not be furnished in accordance with accepted standards of medical 
practice. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance ride was 
ordered by a doctor, and you should not have to pay for it. 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 each one-way Medicare-covered ambulance service.  
 
You have been asked to pay a $275 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 the ambulance 
services provided on November 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you need wound care. The Plan denied 
your request. The Plan says the 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a diagnosis of Pain in left knee due to osteoarthritis, in addition to generalized deconditioning. The 
physical exam on August 29, 2022, was notable for multiple areas of ecchymosis on the knee and lower leg, as 
well as the arms and contralateral side, in various degrees of healing. The enrollee was going to try a steroid 
injection at that time. On September 26, 2022, the enrollee reported continued knee pain, even if it is slightly 
improved. The enrollee was using a walker, but still was having a difficult time getting around. It is 
documented that the enrollee wished to try a course of viscosupplementation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 25, 2022, to October 27, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you did not know you 
would need an authorization to be admitted to the hospital 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 $90 
copayment for in-network emergency services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
in-network emergency services 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 
an emergency room visit provided on October 25, 2022, to October 27, 2022.