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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested treatment order of Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our reviewer says that 
that the requested use of Keytruda is not FDA approved for the enrollees diagnosis. Our physician reviewer 
found that the use of Keytruda is also not supported by one of the major drug compendia or by clinical 
research.  
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended home sleep study (G0399). 
 
You asked the Plan to pre-approve the sleep study. You say that the enrollee was seen in the office for the issue 
of daytime hypersomnolence which has been quite severe. You also say that you suspected sleep apnea was a 
possibility and therefore ordered a home sleep test. The Plan denied your request. The Plan says there is no 
documented increased risk of moderate to severe obstructive sleep apnea (OSA) and therefore this is not 
covered. 
 
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 sleep study. Our reviewer says that 
the request for an unattended home sleep study is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates that the enrollee complains of excessive daytime sleepiness. An undated Epworth sleepiness score was 10. A telephone visit on July 3, 2023, 
describes daytime sleepiness, minimal to no snoring, and no observed apneas. The reviewer found there is no 
additional sleep history provided. The enrollee is not obese. There is no detailed upper airway examination or 
neck circumference. Therefore, the reviewer found that the requested unattended home sleep study 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 the sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an unattended home sleep study (G0399).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on 
November 16, 2022. 
 
You asked the Plan to pay for the TissueCypher Barrett's esophagus assay. You say that this test is a covered 
Medicare benefit. The Plan denied your request. The Plan says that the clinical value and effectiveness of 
TissueCypher Barrett's esophagus assay have not been demonstrated in the peer-reviewed literature. 
 
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 TissueCypher Barrett's esophagus assay. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is substantial data for TissueCypher in patients with Barrett's. 
 
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 TissueCypher Barrett's esophagus assay have been met. Therefore, we 
decided that the Plan has to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on 
November 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
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, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
congestive heart failure and pneumonia. Medical problems are stable. There are 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational items are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has upper extremity weakness following a 
stroke. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the 
requested service. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on May 09, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the enrollee was in a nursing 
home setting at the time services were rendered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services provided on May 09, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for presumptive drug testing (80307) provided on April 5, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says that these services cannot be paid in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial with a 
supporting citation. The services at issue were submitted on an appropriate claim with a valid CLIA number. 
The services are supported in the medical record as results of the presumptive tests were included. The Plan has 
not clearly substantiated their denial in this case. Therefore, we decided that the Plan has to pay for 
presumptive drug testing (80307) provided on April 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for presumptive drug testing (80307) provided on January 19, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says that this service is not payable to this provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial with a 
supporting citation. The services at issue were submitted on an appropriate claim with a valid CLIA number. 
The services are supported in the medical record as results of the presumptive tests were included. The Plan has 
not clearly substantiated their denial in this case. Therefore, we decided that the Plan has to pay for 
presumptive drug testing (80307) provided on January 19, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1, 
2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be liable for the 
copayment due to the quality of care provided at the facility. 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 $0 
copayment for days 1 to 20, a $140 copayment each day for days 21 to 45 and $0 copayment for days 46 to 100 
for SNF care.  
 You have been asked to pay $840 copayment for a SNF stay ($140 per day x 6 days = $840). This item/service 
falls within the SNF 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 the copayment for a SNF stay 
provided from December 1, 2022, to December 21, 2022.  
 
Your complaint about the quality of care received at the facility is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 provided on March 21, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not supported, as the method of testing is not 
documented. 
 
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, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays and enzymatic methods), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We asked our coder 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 procedure code G0482. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found the record does not confirm that definitive drug 
testing was performed on drugs from 15-21 drug classes. This code cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0482 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0482 provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 03, 2023, to May 04, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
provided on May 03, 2023, to May 04, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says Prolia is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a 
diagnosis of "other specified disorders of bone density and structure, unspecified site". The documentation does 
not support that Prolia is medically reasonable and necessary for the enrollee. The documentation does not 
support that Prolia is safe and effective for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this device is considered experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is considered experimental. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99490) provided on April 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 use of code 99490 is 
not supported by the records provided. Our reviewer found that the records for the report month provided does 
not include a signature of the servicing provider. Therefore, there is not sufficient documentation to validate 
that the chronic care management services were provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99490) provided on April 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 the lab services provided on January 27, 2023, by 
an out-of-network (OON) provider.