Persius/hicric huggingface dataset:
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 enrollee requires admission to a 
LTACH. He needs this admission in order to progress to the point where he can return home. The enrollee will 
benefit from tracheostomy rehab and more extensive therapies available at the LTACH. The Plan denied your 
request. The Plan says the enrollee is currently dependent for all of his activities of daily living and cannot 
actively participate in three hours of acute rehab daily. The enrollee is currently in an acute care hospital, and 
the hospital staff indicate that his rehab potential is poor. As a result, none of the services needed require an 
LTACH setting of care. The enrollee's needs can be met at the current acute hospital 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with abdominal pain secondary to small bowel obstruction 
that required operative intervention.  The record indicates that the enrollee has ongoing acute medical issues 
and still requires acute care services.  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 he is not currently 
receiving but that would be available at the LTACH 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521, J1817) provided on 
January 23, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation did not support the billed codes. 
 
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 the infusion services have been met. 
Insufficient records were provided to support the codes billed. No records were provided to show refilling and 
maintenance of a portable pump. Multiple requests for more records were sent by the plan and non were 
provided. Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96521, 
J1817) provided on January 23, 2023.
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 deserve a chance to have proper care and are 
willing to work hard and gain maximum mobility. The Plan denied your request. The Plan says that they need 
more information, such as your doctors' notes, imaging, lab tests, physical and occupational therapy notes and 
hospital progress notes.  
 
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 require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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 an insertion of interlaminar/interspinous process 
stabilization at L5-S1. 
 
You asked the Plan to pre-approve an interlaminar/interspinous device. You say that the enrollee has low back 
pain and has modic changes at L5-S1 and has failed other conservative treatments. The Plan denied your 
request. The Plan says there are currently no clinical indications for this technology. 
 
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 an interlaminar/interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found interspinous devices are 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 an interlaminar/interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process stabilization at L5-
S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the secondary cataract laser surgery 
provided by an in-network provider on May 12, 2022, and May 19, 2022. 
 
You asked the Plan to waive the deductible for the secondary cataract laser surgery. You say that you were 
never told that there would be a deductible applied to these services. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
 
 
 You have been asked to pay a $461.20 deductible for the secondary cataract laser surgery ($230.60 + $230.60 = 
$461.20). The items or services you asked the Plan to waive the deductible for fall within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the 
secondary cataract laser surgery was provided on May 12, 2022, and May 19, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for the secondary cataract laser surgery provided by an in-
network provider on May 12, 2022, and May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis. 
 
You asked the Plan to pre-approve an ankle foot orthosis. You say that you do not agree with the denial 
because an off-the-shelf boot will not accommodate the enrollee's level of deformity. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria needed because they have not owned their current 
equipment for more than 5 years.  
  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a pneumatic walking boot. A pneumatic walking boot serves the same 
purpose as an ankle foot orthosis. Therefore, we decided that the Plan does not have to pre-approve an ankle 
foot orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for lumbar laminectomy surgery. 
 
You asked the Plan to pre-approve the inpatient admission. You say that needs this surgery because you are in 
terrible pain. The Plan denied your request. The Plan says this procedure can be safely performed in an 
observation level of care (which has been approved). You do not have a complicated medical condition that 
would require inpatient admission. 
 
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 inpatient admission. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are a 70-year-old female with a history of Thyroid disease, Urinary incontinence, 
diabetes mellitus, osteoarthritis of the left knee, parotid mass, Myofascial pain, and endometriosis who has been evaluated for chronic low back pain with left-sided sciatica ongoing for 6 months. You have significant 
numbness and tingling radiating down your left lower extremity with weakness. You have had nonoperative 
therapy for over six weeks including failed lumbar epidural injections x2, Hydrocodone. Magnetic resonance 
imaging (MRI) shows severe foraminal stenosis impressing lumbar radiculopathy. You are scheduled for for 
Posterior Lumbar Laminectomy with bilateral Foraminotomies. Based on information received for review, it 
appears that observation status is the appropriate setting for your evaluation and treatment. The review has 
determined that the inpatient admission at issue in this case is not medically reasonable and necessary. Your 
surgery can be safely performed in an observation setting. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient admission for lumbar laminectomy surgery.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 25, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pain management 11 endogenous analysis (0117U) 
provided on October 27, 2022. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT 0117U is non-covered for 
pharmacogenomic testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Pain management 11 endogenous analysis (0117U) provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (0037U) provided on March 1, 2023.  
 
You asked the Plan to pay for FoundationOne CDx. You say that this testing was medically necessary The Plan 
denied your request. The Plan says under Medicare guidelines, your request is not medically necessary because 
your records do not show either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer or 
that you have decided to seek further treatment.  
 The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for FoundationOne CDx. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that although molecular profiling is often 
considered a standard of care for lung cancer there are no medical records provided to explain the rationale for 
testing with FoundationOne. There is not staging, histology, or prior treatments. The service was 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 FoundationOne CDx have not been met. Therefore, we decided that the Plan 
does not have to pay for FoundationOne CDx (0037U) provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 14, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the enrollee needs this to help improve 
their symptoms.  The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, the record does not support that the enrollee 
is enrolled in a clinical trial. Therefore, we decided that the Plan does not have to pre-approve a leadless 
pacemaker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on 
December 27, 2022. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on December 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutritional therapy provided on October 26, 
2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services should be covered. 
The Plan denied your request. The Plan says the enrollee has exhausted the Plan's benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records indicate the enrollee has exhausted the Plan's benefit. The Health Plan verified the enrollee 
received 12, 15 minutes medical nutrition therapy from April 1, 2022, through June 30l, 2022. This equals 3 hours of nutritional therapy which meant there was no benefit left at the time of service. Therefore, we decided 
that the Plan does not have to pay for the medical nutritional therapy provided on October 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service January 10, 
2022, to February 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that you have no way to show proof of timely filing. 
The Plan denied your request. The Plan says an NOA was not submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, there is no documentation to show that a valid NOA was submitted as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health care billed for dates of service January 10, 
2022, to February 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service December 8, 
2022, to January 6, 2023. You asked the Plan to pay for the billed services. You say that the NOA was sent per Medicare guidelines. The 
Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 8, 2022. The NOA was not received by the Plan until February 
17, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service December 8, 2022, to January 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ontruzant. 
 You asked the Plan to pre-approve Ontruzant. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the Plan requires a trial of Kanjinti or Trazimera before it will approve 
Ontruzant. 
 
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 Ontruzant. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Ontruzant. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Kanjinti or Trazimera. The record does not show 
that one of these drugs would likely be less effective and/or have adverse effects 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 Ontruzant have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ontruzant.
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 services are medically necessary for the enrollee 
after their amputation to maximize their ability to return to their prior level of independence. The Plan denied 
your request. The Plan says the enrollee does not meet the 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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.