Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you were given misinformation about this coverage. 
The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx testing for prostate cancer (0339U) provided on 
January 4, 2023. 
 
You asked the Plan to pay for SelectMDx. You say that this test does not meet the criteria for medical 
necessity. The Plan denied your request. The Plan says this is a covered test which was medically necessary for 
the enrollee. 
 
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 pay for SelectMDx. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of liquid biopsy to determine the risk of prostate cancer is not considered a standard of 
care. Use is not supported by the NCCN Guidelines or the medical literature. The use of SelectMDx is 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 SelectMDx have not been met. Therefore, we decided that the Plan does not 
have to pay for SelectMDx testing for prostate cancer (0339U) provided on January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on October 
19, 2022. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this test was medically necessary. 
The Plan denied your request. The Plan says this test is not covered. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that this is a medical necessity. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 9, 2022, to 
August 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code 
Our physician reviewer found that the enrollee is an 81-year-old female with dementia, chronic kidney disease 
stage 3, and Diabetes mellitus who was treated in the hospital. She presented with altered mental status and was 
found to have a urinalysis suggestive of infection. She was started on antibiotics and intravenous fluids, which 
complicated by rash, then given steroids and Benadryl. Glasgow Coma Scale was 13. Following fluids, workup 
revealed normal bilirubin, normal and stable blood pressure, baseline creatinine, no acute mental status change, 
normal platelets, and no hypoxia suggesting no organ failure related to the infection as a result of a 
dysregulated response. Sepsis 3 criteria was not met. Therefore, the code, A41.9 (sepsis), was not sufficiently 
supported in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 9, 2022, to August 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that other treatments are more lengthy 
and expensive than brachytherapy. The Plan denied your request. The Plan says this is 
experimental/investigational. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found certainly using ultrasound on a daily basis is not unreasonable to offer, but is not 
necessary. The device itself is Food & Drug Administration approved for use with ultrasound though that in-
and-of itself does not mean that daily imaging is necessary. Therefore, performing daily image-guided radiation therapy which 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver (64590). 
 
You asked the Plan to pre-approve the insertion or replacement of peripheral or gastric neurostimulator pulse 
generator or receiver. You say that the service is medically necessary. The Plan denied your request. The Plan 
says that the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation 
involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a 
permanent implantation in appropriate candidates. Both the test and the permanent implantation are 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 insertion or replacement of 
peripheral or gastric neurostimulator pulse generator or receiver. Our reviewer says that the service is 
medically necessary. Our physician reviewer found The review indicates that the enrollee has urinary retention. 
A urodynamic study on January 1st, 2023, showed incomplete bladder emptying. She reported subjective 
improvement on Flomax but continued to have post-void residuals of 300-500 milliliters. The enrolle was not 
felt to be a candidate for intermittent catheterization due size. 
 
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 insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver have been met. Therefore, we decided that the Plan has to pre-approve the insertion or 
replacement of peripheral or gastric neurostimulator pulse generator or receiver (64590).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia (49650) 
on October 21, 2022. 
 
You asked the Plan to pay for laparoscopy, surgical; repair initial inguinal hernia. You say that the out-of-
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in-network primary physician and in-network facility. The Plan denied your 
request. The Plan says this provider specialty does not have the capacity to bill directly for the services 
rendered. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare makes payment for an assistant at 
surgery when the procedure is authorized for an assistant and the person performing the service is a physician, 
physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laparoscopy, surgical; repair initial inguinal hernia have not been met. The services were rendered 
by a provider who is credentialed as a Registered Nurse - Registered Nurse First Assistant. This provider 
specialty does not have the capacity to bill directly for the services rendered. Therefore, we decided that the 
Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia (49650) on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet-rich plasma (PRP) injections. 
 
You asked the Plan to pre-approve PRP injections. You say that you are not able to do daily activities without 
pain. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that PRP injections for musculoskeletal injuries 
and/or joint conditions are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PRP injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve platelet-rich plasma (PRP) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve injections. You say that the denial is unwarranted and unsupported by the 
enrollee's current medical status and is inconsistent with currently accepted medical practice. The Plan denied 
your request. The Plan says the injections are considered experimental and/or investigational. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for intervertebral disc degeneration. She presented with axial 
lumbar spine pain with radiation towards the left hip. Activities such as prolonged sitting and bending forward 
exacerbate her pain. She has imaging evidence of degenerative disc disease most notably at the L4-5 and L5-S1 
levels. The exam reveals no focal strength or sensory deficits. There is decreased range of motion with pain on 
forward bending. Positive sustained hip flexion test is noted. Reflexes are 1+ at bilateral patella and Achilles. 
Gait is antalgic. However, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested ViaDisc, in this case, 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the drug injection provided on August 8, 2022. We 
also decided that the Plan does not have to waive the copayment for the arthrocentesis provided on August 8, 
2022.  You asked the Plan to waive the cost share for the drug injection and arthrocentesis. You say that this should be 
fully covered by the Plan. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the drug injection provided on August 8, 
2022.  
 
The Plan says you must pay $248.52, which is 20.3% coinsurance for the drug injection. Based on the Plan 
contract, however, you cannot be asked to pay more than $244.54, which is 20% coinsurance of the allowed 
amount on the Explanation of Benefits for the drug injection ($1,222.72 allowed amount x 20% coinsurance = 
$244.54). Therefore, we decided that the Plan has to reduce the coinsurance for the drug injection provided on 
August 8, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the arthrocentesis provided on 
August 8, 2022. 
 
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 $325 
copayment for each in-network outpatient surgery.  
 
According to Medicare the arthrocentesis (code 20610) is considered outpatient surgery. You have been asked 
to pay $155.64, which is less than the standard $325 copayment for the arthrocentesis. 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 arthrocentesis provided on August 8, 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 the enrollee will clearly benefit from acute rehab to 
optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says that the 
enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation facility. 
 
  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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
We looked at the file and Medicare rules. Although a seat lift chair may be appropriate, Medicare does not 
cover this item and the Plan must provide coverage only for items that Medicare covers. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a seat lift chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the record does not show that the enrollee has been 
evaluated by a spine surgeon and a psychologist. 
 The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered if certain 
conditions are met. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for a spinal cord stimulator. Our physician reviewer found the 
record does not show a psychological evaluation and clearance. No surgical consultation is documented. The 
enrollee does not have an evidence-based indications for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.