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

 
We decided that the Plan does not have to pay for MyBestMed pharmacogenomics testing provided on 
February 2, 2023. 
 
You asked the Plan to pay for MyBestMed testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of MyBestMed testing have not been met. Therefore, we decided that the Plan 
does not have to pay for MyBestMed pharmacogenomics testing provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits.  
 
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. 
 
   
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a partial lower denture (D5214) to be provided by an out-of-network provider.
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 are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided 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 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: 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 would benefit from intensive rehab 
where they will be managed and monitored closely. The Plan denied your request. The Plan says the enrollee's 
needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. The complexity of the enrollee's nursing, rehab, and 
medical needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such an 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 inpatient rehabilitation facility (IRF) admission and services.
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 rehab would provide you with the equipment and 
therapy services needed. The Plan denied your request. The Plan says your needs can be met at an alternate 
level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have acute, intensive or complex rehabilitation needs. You do not 
require frequent physiatry oversight or 24-hour rehabilitation nursing care. The rules for coverage are not met 
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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator. 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the enrollee is a suitable candidate 
for spinal cord stimulation. The Plan denied your request. The Plan says the enrollee does not have a qualifying 
diagnosis. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have a qualifying condition for the spinal cord stimulator. 
Detailed documentation is not evident regarding a qualifying diagnosis or symptoms that have not responded to 
medical 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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
are not medically necessary. 
 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity for the requested MRI lumbar spine without the completion of a supervised 6 week physical therapy 
program has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 9, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 9, 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 enrollee had back surgery and can no longer be 
in the hospital. You also say that the enrollee needs the rehabilitation immediately. The Plan denied your 
request. The Plan says the enrollee does 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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar surgery. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the medical records support 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent bridge (D2950 x 2, D6740 x 2, D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a replacement 
permanent tooth that broke off. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. The Plans rule for coverage state when you 
are missing teeth on both sides of your upper or lower jaw, the Plan will only pay for a partial denture. 
 
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 dental services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record shows tooth numbers 
17, 19, 31 and 32 are missing in the lower arch. Therefore, the Plans rules for or coverage have not been met. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a permanent bridge (D2950 x 2, D6740 x 2, D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the requested procedure 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 a Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex procedure is experimental, and 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical or vaginal cytopathology (88142) provided on 
February 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for cervical or vaginal cytopathology. You say that the pathologist does not have 
access to the enrollee's insurance information. The Plan denied your request. The Plan says this service is not 
covered when provided OON without prior approval. 
 
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 cervical or vaginal cytopathology (88142) 
provided on February 8, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 21, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported as billed. The Plan denied your request. The Plan says there is insufficient documentation to process 
this claim. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the order form does not include the referring provider's signature. There are also no physician 
notes documenting intent for this test to be performed or supporting medical necessity of these tests. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223, 99238, 99232) provided on November 
21, 2022 to November 25, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 inpatient services. Our reviewer says that the codes billed 
are not supported by the records. Our reviewer found the records do not show medical decision making of high 
complexity to support code 99223. There was no discharge note to support code 99238 and no evaluation and 
management note for the billed service dates to support code 99232.  
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient care (99223, 99238, 99232) provided on November 21, 2022 to November 
25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed at 
conservation treatment without relief. The appellant states the denial is inconsistent with the benefits of the 
Intracept procedure. The Plan denied your request. The Plan says medical studies have not proven this service 
is helpful for treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the imaging from September 6, 2022, did not corroborate Modic changes at the 
requested surgical level. Additionally, there are multiple plausible pathologic sources of significant pain 
generation. The documentation does not support formal surgical ablation of pre-designated basivertebral nerves 
as being medically necessary or reasonable 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy services. 
 
You asked the Plan to pre-approve the radiation therapy. You say that the requested treatment is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested treatment is not 
medically necessary for the enrollee's condition. 
 
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 pre-approve the radiation therapy. Our reviewer says 
that the requested radiation therapy services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the published data and guidelines establish radiotherapy as an acceptable 
standard of care for the enrollee's condition. Therefore, the reviewer found that the requested treatment is 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiation therapy have been met. Therefore, we decided that the Plan has to 
pre-approve radiation therapy services.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris infusions. 
 You asked the Plan to pre-approve Soliris. You say that you have trialed prednisone and mestinon with no 
symptom relief. You also say that your doctors feel that this treatment would be a good option for you. The 
Plan denied your request. The Plan says the enrollee has not tried and failed a generic immunosuppressant drug 
and Vyvgart. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Soliris. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drugs. The reviewer also found that here is no documentation 
provided indicating that the plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Soliris infusions.