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

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis and full duplication/deletion analysis (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that you have been diagnosed with breast cancer 
and you have a strong family history of close family members with breast cancer and other cancers. The Plan 
denied your request. The Plan says the criteria are not met for triple negative breast cancer. Criteria are not met 
for an enrollee with breast cancer diagnosed at any age. The Plan also says the state where the provider 
performs the service differs from the state where you reside. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that if you are diagnosed at any age, with at least 
one close blood relative with breast cancer at age 50 or younger; or diagnosed at any age with at least one close 
blood relative with epithelial ovarian cancer, fallopian tube, or primary peritoneal cancer; then the genetic 
testing would be medically necessary. The records show that your family history is significant for breast cancer 
in a maternal cousin. Based on this information, we decided that Medicare rules for coverage of genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA 
repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene 
analysis; full sequence analysis and full duplication/deletion analysis (81162).
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 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. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted with acute hypoxic respiratory failure due to COVID-19 pneumonia. The enrollee continues to receive 
acute care services and these have not been denied. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. The 
LTACH services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the power wheelchair is being requested primarily for 
community use and is not covered for this purpose. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (K0823).
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 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. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted with colonic obstruction, requiring operative intervention. The enrollee continues to receive acute care 
services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH facility. The LTACH 
services are 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 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 therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of the therapeutic CGM have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lung volume reduction surgery (LVRS) services. 
 
You asked the Plan to pre-approve LVRS services. You say that this procedure is medically necessary as you 
are in a lot of pain. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for services performed on or after 
January 1, 2004, Medicare will only consider lung volume reduction surgery (LVRS) reasonable and necessary 
when the enrollee's body mass index (BMI) is less than 31.1 kg/m2 for men. 
 
We looked at the file and Medicare rules. In this case, your BMI is not less than 31.1kg/m2.  Based on this 
information, we decided that Medicare rules for coverage of LVRS services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lung volume reduction surgery (LVRS) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Patent Foramen Ovale (PFO) closure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk for other 
complications. The Plan denied your request. The Plan says the request 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 requested services. Our physician 
reviewer found that the enrollee had a stroke in 2017. A transesophageal echocardiogram at that time showed a 
PFO with normal right and left sided chambers size and no evidence of intramural thrombus. A recent 
echocardiogram confirmed a PFO with normal sized right atrium and ventricle without any evidence of 
intramural thrombus. The enrollee has had no recurrence of symptoms. There is no echo evidence of cardiac 
chamber dilatation, evidence of cryptogenic stroke with paradoxical embolism, exertional hypoxemia or 
significant left to right shunt. As such, guidelines would not support the need for a PFO closure device. In 
summary, there is insufficient documentation to support the medical necessity for the requested PFO closure 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Patent Foramen Ovale (PFO) closure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an AngelMed Guardian System. 
 
You asked the Plan to pre-approve the requested services. You say that the device offers a more rapid 
beneficial resolution than the standard of care. The Plan denied your request. The Plan says there is a lack of 
evidence to support the system is safe and effective. 
 
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 requested services. Our physician 
reviewer found that an exhaustive review of the current medical literature pertaining to the AngelMed Guardian 
system confirms several observational studies suggesting clinical benefit. While the clinical studies led to FDA 
approval, the AngelMed Guardian system remains the subject of studies assessing long-term efficacy, as well 
as randomized, controlled, blinded trials to quantify clinical efficacy. Until such statistically rigorous studies 
are completed, it is premature to presume clinical outcomes and benefit. At the current time, the AngelMed 
Guardian system is not considered to be medically necessary for 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an AngelMed Guardian System.
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 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. 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
with a femur fracture after a fall. You are now medically stable with no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5210). 
 
You asked the Plan to pre-approve the dental services. You say that You say that your gums are deteriorating, 
and you are afraid you will not have any gums to chew your food. You say that your gums are constantly 
hurting and cannot invest in a new set of teeth. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 5, 2020, for the 
maxillary complete denture (D5110), and April 6, 2021, for the mandibular complete denture (D5120). 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5210).
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 the enrollee would lack the ability to regain 
maximum function at a lower level of care. The Plan denied your request. The Plan says rules for IRF care 
have not been met. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. The Plan denied your request. The Plan says that therapy 
services are available 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 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 
occupational therapy 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 waive the cost share for an in-network specialist visit for an injection 
provided on April 15, 2022. 
 
You asked the Plan to waive the cost share for an in-network specialist visit for an injection. You say that you 
did not think you would have this care of a charge for this visit. The Plan denied your request. The Plan says 
the cost share applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for a specialist visit and 20% coinsurance for Medicare Part B drugs. The allowed amount of this 
injection is $506.07, resulting in a coinsurance amount of $101.21 ($506.07 x 20% = $101.21 + $25 = 
$126.21). 
 
You have been asked to pay a $25 copayment for a specialist visit and $101.21 coinsurance for Medicare Part 
B drugs for an in-network specialist visit for an injection ($101.21 + $25 = $126.21).  
 An in-network specialist visit for an injection falls within the for Medicare Part B Drugs, and 
Physician/Practitioner 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 cost share for an 
in-network specialist visit for an injection provided on April 15, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You have had a decline in your baseline level of function and 
would likely benefit from therapy, but the documentation is insufficient in terms of indicating that you have the 
strength and endurance to participate in the intensity of therapy services provided in acute inpatient 
rehabilitation. 
 
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: 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 required services are not available at 
a lower level of care. The Plan denied your request. The Plan says the enrollee's care can be received in a less 
intensive setting. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he/she is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The health plan has approved ongoing care in the current acute care setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 19, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator equipment rental. 
 
You asked the Plan to pre-approve portable oxygen concentrator equipment rental. You say that the provider 
has only received 17 payments. The Plan denied your request. The Plan says the requested item exceeds the 
rental limit. 
 
The Plan must follow Medicare rules. Medicare rules say that after 36 rental payments have been made, no 
additional payment can be made for oxygen equipment. 
 
We looked at the file and Medicare rules. Review of the file shows that you have been using oxygen since July 
2018. The rules state that oxygen equipment is limited to 36 months of rental. The documentation shows that 
you have rented oxygen equipment for 36 months. Based on this information, we decided that Medicare rules 
for coverage of portable oxygen concentrator equipment rental have not been met. Therefore, we decided that 
the Plan does not have to pre-approve portable oxygen concentrator equipment rental.