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

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing and 
hereditary genetic cardiac testing provided December 28, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says the records 
do not support that the enrollee meets the criteria. 
 
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 the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the enrollee underwent comprehensive hereditary 
pharmacogenomic testing and hereditary genetic cardiac testing. The enrollee has a history of diabetes mellitus, 
hypercholesterolemia, hypertension, coronary artery disease, atrial fibrillation, peripheral vascular disease, 
rheumatoid arthritis, and chronic pain. There is no documentation of any adverse drug reactions. There is no 
documentation from the provider documenting the specific drugs being considered for use, and no 
documentation to how the results will specifically impact treatment. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac 
testing provided December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the records show that the NIV is going to be used 
only in a CPAP/Bi-level PAP mode and the records do not show that the enrollee failed management with 
BiPAP. Under Medicare, the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with acute on chronic renal failure and hyperkalemia. Diagnoses include Huntington's disease, obstructive sleep 
apnea, and congestive heart failure. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease that would cause diaphragmatic weakness. ABG on admission was consistent with severe acute on 
chronic hypercarbic respiratory failure. The enrollee improved with BiPAP. A diagnosis of COPD is 
mentioned, but there does not appear to be a history of COPD and the enrollee is a lifetime non-smoker. There 
are no pulmonary function tests to confirm airways obstruction or assess severity. There is no ABG done while 
stable to document chronic CO2 retention. If that is present, the enrollee may benefit from BiPAP with AVAPS 
during sleep. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Gel-one. Our reviewer says that the 
enrollee does not meet the coverage criteria for Gel-one. Our physician reviewer found based on the medical 
records provided there is no indication that the enrollee has tried and failed the required drugs. Our reviewer 
also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely 
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 Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for sepsis, urinary tract infection, and gout. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that 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 prosthetics and associated accessories (L5673, L5705, 
L8460, L5968, L5671, L5850, L5845, L5651, L5925, L5920, 8430, L5624, L5964, L5812, L5321, L5950, 
L5650, L5649, L5631, L5972) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthetics and associated accessories. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not have out 
of network coverage.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
prosthetics and associated accessories (L5673, L5705, L8460, L5968, L5671, L5850, L5845, L5651, L5925, 
L5920, 8430, L5624, L5964, L5812, L5321, L5950, L5650, L5649, L5631, L5972) to be provided by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing provided on March 18, 2022.  
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this claim should not be denied as experimental/investigational. The Plan denied your request. The Plan says 
there is no documentation of Barrett's Esophagitis/dysplasia.  
 
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 the WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the provided records in this 
case do not document the testing is safe and effective, not mainly for the convenience of the enrollee or the 
physician, not experimental or investigational, is appropriate, is furnished in accordance with accepted 
standards of medical practice for the diagnosis or treatment of the enrollees condition or to improve the 
function of a malformed body member, is furnished in a setting appropriate to the enrollees medical needs and 
condition, is ordered and furnished by qualified personnel, is one that meets, but does not exceed, the enrollees 
medical need and is at least as beneficial as an existing and available medically appropriate alternative. 
 
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 WATS cytopathology and histopathology diagnostic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the WATS cytopathology and histopathology 
diagnostic testing provided on March 18, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic Brachytherapy and therapeutic radiology 
simulation-aided field setting. 
 
You asked the Plan to pre-approve electronic Brachytherapy and therapeutic radiology simulation-aided field 
setting. You say that the requested electronic Brachytherapy and therapeutic radiology simulation-aided field 
setting is medically necessary. The Plan denied your request. The Plan says the requested electronic 
Brachytherapy and therapeutic radiology simulation-aided field setting 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 electronic Brachytherapy and 
therapeutic radiology simulation-aided field setting. Our reviewer says that the requested electronic 
Brachytherapy and therapeutic radiology simulation-aided field setting is not medically necessary. Our physician reviewer found radiation is a standard approach to the treatment of skin cancer and is often preferred 
over surgery when resection is likely to result in unacceptable morbidity or cosmesis. Many factors determine 
which of many treatments are best suited for an individual patient- including histology (squamous cell or basal 
cell carcinoma), size (T stage), depth, location, and comorbidities. 
 
The most recent National Comprehensive Cancer Network (NCCN) guidelines for basal cell and squamous cell 
skin cancers explicitly state There are insufficient long-term efficacy and safety data to support routine use of 
electronic surface brachytherapy. Earlier versions (1.2016 and before) did not specifically address electronic 
brachytherapy (EBT) or superficial radiation (SRT), and only mentioned electron and orthovoltage beams as 
means to deliver radiation. Generally, electron therapy or orthovoltage therapy are considered standard means 
to deliver radiation.  
 
For this case, there are no compelling reasons offered for why SRT would be needed over more standard 
approaches of radiation delivery. 
 
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 and therapeutic radiology simulation-aided field 
setting have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic 
Brachytherapy and therapeutic radiology simulation-aided field setting.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit . You say that this should be covered. The Plan denied your 
request. The Plan says there are in-network providers who can treat the enrollee. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 16, 2022, to 
February 14, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
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 January 16, 2022. The NOA was not received by the Plan until October 5, 
2022. 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 home health services provided 
from January 16, 2022, to February 14, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does require the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. The enrollee was hospitalized on June 2, 2023, for sepsis and 
pneumonia. Other medical issues included COVID-19 infection, acute on chronic renal failure and pressure 
wounds. The enrollee wound benefit from physician oversight for closer monitoring of antibiotics and his 
kidney function. The enrollee would also benefit from skilled nursing care given his pressure wounds. Initially, 
the enrollee had difficulty participating in therapy and following commands, but the most recent documentation 
indicates that he is following verbal cues 75% of the time and has made progress with bed mobility and 
performing transfers. The enrollee would benefit from physical and occupational therapies. 
 
   
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tempus xF liquid biopsy. 
 
You asked the Plan to pre-approve the Tempus xF liquid biopsy. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid 
biopsy have not been met. Therefore, we decided that the Plan does not have to pre-approve the Tempus xF 
liquid biopsy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom motorized/power wheelchair base (K0013). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the scooter you were approved for does 
not work properly. You would like to return the scooter and get an electric power wheelchair instead. The Plan 
denied your request. The Plan says you were approved for a group 2 scooter not a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 The records show that you were approved for a scooter on May 25, 2022. The records also show that there has 
not been a change in your condition, and you need a new evaluation to determine your current needs. The file 
shows that you cannot safely operate the PMD being requested. This means that Medicare rules for coverage of 
a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom 
motorized/power wheelchair base (K0013).