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

 
We decided that the Plan does not have to pre-approve a FoundationOne Liquid Biopsy Test. 
 
You asked the Plan to pre-approve a FoundationOne Liquid Biopsy Test. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when specific criteria 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 a FoundationOne Liquid Biopsy Test. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review 
indicates that Medicare provides coverage for liquid biopsy testing only when tissue biopsy and testing has 
been unsuccessful or is not feasible. Based on the lack of documentation indicating that tissue biopsy and 
testing is unsuccessful or not feasible the review has determined that you do not meet the coverage criteria 
detailed in the NCD. 
 
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 FoundationOne Liquid Biopsy Test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FoundationOne Liquid Biopsy Test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2023, billed with 
codes 81225, 81227, 81231, 81232, 81306, 81335, 81291 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2023, billed with codes 81225, 81227, 81231, 81232, 81306, 81335, 81291 and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extra covering for a prosthetic leg (L5962). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations 
where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by 
L5704, L5705, L5706, and L5707.  
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no justification or context found in the record to suggest that this enrollees prostheses will be 
exposed to unusually harsh environments necessitating additional protection beyond what is provided with a 
typical cover, e.g., L5704, which has already been approved by the plan. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extra covering for a prosthetic leg (L5962).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on June 18, 2021, to July 23, 
2021. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the requested documentation has not been 
provided for review. 
 
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 inpatient hospital care provided 
have been met. Specifically, the requested itemized billing summary has not been provided for review. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on June 18, 2021, 
to July 23, 2021.
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 is not ready to be discharged home they 
may have another fall or seizure. The Plan denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #21, 22, 23, 24, 
25, 26, and 29 and extractions (D7140) of tooth #26 and 29. 
 
You asked the Plan to pre-approve the extractions. You say that you are requesting reconsideration of the 
denied dental services. The Plan denied your request. The Plan says your benefit for the requested dental 
services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee had an extraction of tooth #30 (D7140) on date of service June 20, 2023. The Plan approved 
the extraction of tooth #18 and 19 (D7210) and tooth #21, 22, 23, 24, and 25 (D7140) on the initial authorization. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) of 
tooth #21, 22, 23, 24, 25, 26, and 29 and extractions (D7140) of tooth #26 and 29.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Rituxan (J9312). 
 
You asked the Plan to pre-approve the medication. You say that Rituxan is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says Rituxan has been prescribed for an off-label, not medically 
accepted use. 
 
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 physician reviewer 
found the requested use of Rituxan Food and Drug Administration (FDA)-approved for the enrollees diagnosis 
because Rituximab is not FDA approved for use in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Rituximab is not currently supported for use in the Compendia. Nor was any 
research provided to support the Centers for Medicare & Medicaid Services (CMS)-approved medical journal 
requirement. 
 
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 treatment with Rituxan (J9312).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the records do not show that is it medically necessary 
for the enrollee to be in an LTACH in place of an acute care hospital. 
 
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 appears to be improving and should only require short-term additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate  
 for transfer to a lower level of care soon. The patient does not require services at the LTACH that are not 
already available at the current 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the durable medical equipment (DME) (E0163, 
K0001, E0627, E0978, E0621, E0627) purchased June 11, 2021, to January 22, 2023. 
 
You asked the Plan to reimburse you for the DME. You say that please proceed to process the medical 
equipment claim you have previously filed, which included the signed doctor's orders and receipts for all items. 
The Plan denied your request. The Plan says the DME items were purchased from retail suppliers that do not 
participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the durable medical 
equipment (DME) (E0163, K0001, E0627, E0978, E0621, E0627) purchased June 11, 2021, to January 22, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF services are medically necessary. 
The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Embr Wave thermal wristband. 
 
You asked the Plan to pre-approve Embr Wave thermal wristband. You say that you are appealing the denial 
because you believe this is something that can medically help you without having to take more pills. The Plan 
denied your request. The Plan says the requested device does not meet the definition of DME and is not 
primarily a medical device and is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Embr Wave thermal wristband.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided April 24, 2023.  
You asked the Plan to pay for the service. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are 
not used in clinical management, exceeds the needs of the member. Under Medicare rules, the number of 
definitive urine drug classes requested are not 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 service. Our physician reviewer found 
the definitive testing would be reasonable only for opiates, Amphetamines and Barbiturates. The other 18 
classes are not medically reasonable and necessary. Therefore, the code billed is not 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided April 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of plan referral for collagen knee injection. 
 You asked the Plan to pre-approve out of plan referral for collagen knee injection. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 out of plan referral for collagen knee 
injection. 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 osteoarthritis of the left 
knee.  However, of note, there were no formal diagnostic imaging studies provided for review to corroborate 
this diagnosis. The enrollee has trialed previous viscosupplementation injections, most recently on February 17, 
2023, with no benefit from the injections reported. 
 
Further studies are needed to corroborate the safety/efficacy of repeat injections of viscosupplementation for 
knee osteoarthritis without benefit demonstrated from previous injections. There is limited published, large-
scale, long-term peer-reviewed literature demonstrating one course of injectable treatment being more 
efficacious of the other. Therefore, the Plans offer of viscosupplementation injections with hyaluronic acid 
would not be sufficient for the enrollee rather than the requested collagen knee injections. However, the 
documentation does not support that the enrollee has a fully established diagnosis/condition that meets the 
criteria for the requested collagen knee injections.  
 
There is a need for further studies to corroborate the safety and efficacy of collagen injections for the treatment 
of knee osteoarthritis. Without clear peer-reviewed evidence of one treatment modality providing greater 
efficacy over another, treatment should rely on significantly proven treatment modalities. This would typically 
include viscosupplementation injections over collagen injections. However, there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception, 
in this clinical setting. Therefore, the requested collagen knee injection 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 out of plan referral for collagen knee injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve out of plan referral for collagen knee injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF services are medically necessary. 
The Plan denied your request. The Plan says the enrollee does not need therapy or nursing services every day 
that are only on an inpatient basis in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. 
The enrollee is functioning at his baseline. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs can, as a practical 
matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate  
 for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that are not 
already available at the current 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 LTACH services.