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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee will receive the level of care needed to 
manage medications, strength building, maximize mobility, blood sugar management, wound management, as 
well as monitoring for recurrent infection and assistance with activities of daily living. The Plan denied your 
request. The Plan says the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient 
rehabilitation facility.  
 
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 the enrollee does not have documented skilled nursing needs. The enrollee appears to 
be nearing a plateau in therapy. Ongoing daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollee can complete their current course 
of treatment, before being discharged to 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R Interspinous 
device to L4-L5 (22853, 22612, 20930). 
 
You asked the Plan to pre-approve implantation of the Minuteman G3R Interspinous device to L4-L5. You say 
that this is medically necessary. The Plan denied your request. The Plan says interspinous-interlaminar fusion 
surgery and the devices used for it remain experimental for use. More research is needed to show safety and 
efficacy of the procedure and the devices. 
 
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 implantation of the Minuteman G3R 
Interspinous device to L4-L5. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the Minuteman spinal device is 
experimental. 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 implantation of the Minuteman G3R Interspinous device to L4-L5 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the Minuteman 
G3R Interspinous device to L4-L5 (22853, 22612, 20930).
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 the enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an LTACH care. The enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for transfer or discharge. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualifies for SNF care. The enrollee does not have documented 
skilled therapy or skilled nursing needs. The enrollee's care needs can be met in 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on February 01, 2023. 
 
You asked the Plan to pay for the mental health services. You say that the service was medically necessary. 
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 mental health 
services provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
January 17, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99213). You say that the service should be 
covered. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for hysician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the office visit (99213). This item/service falls within the 
hysician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 office visit (99213) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 24, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on February 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
cognitive decline. The record provided does not establish that the enrollee meets the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia or that the requested examination is being requested in the 
context of a clinical trial. The elements of the coverage criteria are not satisfied.  The requested service is not 
recommended. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Cerebral Cavernous Malformation panel (81479) 
provided December 29, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered genetic testing 
for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The 
Plan says this testing is considered investigational and experimental and does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. This is a noncovered test per Diagnostics Exchange (DEX) Registry. 
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 Invitae Cerebral Cavernous Malformation 
panel (81479) provided December 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx (81479) provided on September 23, 2022. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx have 
been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx (81479) provided on September 
23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tubing supplies (A7034, A4604) provided on March 20, 
2023. 
 
You asked the Plan to pay for the tubing supplies. You say that these items were medically necessary. The Plan 
denied your request. The Plan says the amount of units billed exceeds the allowed amount per the coverage 
policy. 
 
The Plan must follow Medicare rules. Medicare rules say that  quantities of supplies greater than those 
described in the policy as the usual maximum amounts will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Codes A7034 and A4604 are allowed at 1 unit per every three 
months. These codes were previously billed January 26, 2023. Based on this information, we decided that 
Medicare rules for coverage of the tubing supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for tubing supplies (A7034, A4604) provided on March 20, 2023.
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 is now making purposeful 
movements and moving their extremities. The appellant states the LTACH is medically necessary. The Plan 
denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee's needs 
are being met in the current 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 to the acute care hospital with trauma after a motor vehicle 
accident including fractures, complicated by subarachnoid hemorrhage, pneumonia, bacteremia, a gastrointestinal bleed, and pneumothorax requiring chest tube placement, blood transfusions, ventilation 
support, trachea placement, and percutaneous endoscopic gastrostomy (PEG) placement. The enrollee appears 
to be improving and more stable and should require only short-term additional acute care hospital services that 
can safely be provided at the current facility until more stable and appropriate for a lower level of care soon. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
7, 2023. 
 
You asked the Plan to pay for 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 NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. 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 pay for the Tempus xF liquid biopsy (81455) provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopantogram and hospital outpatient clinic visit for 
assessment provided on November 18, 2022. 
 
You asked the Plan to pay for orthopantogram and hospital outpatient clinic visit for assessment. You say that 
this service is supported in the records. 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 orthopantogram and 
hospital outpatient clinic visit for assessment provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided on April 04, 
2022, to April 15, 2022. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you disagree with the 
coinsurance. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient diagnostic tests/radiation therapy. 
 
You have been asked to pay 20% coinsurance for radiation therapy. This item/service falls within the outpatient 
diagnostic tests/radiation therapy benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the radiation therapy is $19,671.45. You are being 
asked to pay $3,934.29 ($19,671.45 x 20% = $3,934.29). Therefore, we decided that the Plan does not have to 
waive the coinsurance for radiation therapy provided on April 04, 2022, to April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, and E2603). 
 You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. The Plan denied your request. The Plan says the enrollee does not have a 
qualifying diagnosis causing mobility limitation for which group 3 power wheelchair is medically needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with multiple power options (K0861) and additional items and accessories 
(codes E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, and E2603).  
 
Please Note: If you wish, you may contact the Plan regarding the alternative written order you submitted for a 
group 2 power wheelchair.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
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 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. 
 
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.