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

 
We decided that the Plan does not have to pre-approve the TissueCypher genetic test for Barrett's esophagus. 
 
You asked the Plan to pre-approve the TissueCypher genetic test for Barrett's esophagus. You say that the 
results of this testing will impact the patient's treatment plan. The Plan denied your request. The Plan says 
TissueCypher genetic test for Barrett's esophagus does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say current molecular diagnostic tests that identify individuals 
with upper gastrointestinal metaplasia, dysplasia, and neoplasia are non-covered by this contractor. 
 
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 TissueCypher genetic test for 
Barrett's esophagus. Our reviewer says that the TissueCypher genetic test for Barrett's esophagus is not 
considered medically necessary. Our physician reviewer found that per the Medicare LCD, current molecular 
diagnostic tests that identify individuals with UGI metaplasia, dysplasia, and neoplasia are non-covered. 
Specifically, histological assessment remains the gold standard for dysplasia detection, and available data does 
not support equivalence nor superiority of the TissueCypher assay nor that the service under review has been 
established by specialty society guidance as reasonable and necessary in this case.   
 
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 TissueCypher genetic test for Barrett's esophagus have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the TissueCypher genetic test for Barrett's 
esophagus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels, each (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you need this device to get around for day 
activity. The Plan denied your request. The Plan says The requested service is not covered by Medicare or the 
Plan as there is lack of evidence of safety and efficiacy. 
 
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. There is insufficient published clinical literature demonstrating 
safety and effectiveness to establish the medical necessity for these products. Based on this information, we 
decided that Medicare rules for coverage of a crutch substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without wheels, each 
(E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee was approved an electric 
scooter but is unable to use it due to not having a ramp. The enrollee cannot get in and out of the house. The 
Plan denied your request. The Plan says this item is not a covered benefit with Medicare. 
 
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 a wheelchair ramp (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried the preferred medication 
and it is not working. You say that the clinical documentation supports the medical necessity of the requested 
drug.  The Plan denied your request. The Plan says Vabysmo is not supported for the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 enrollee has branched retinal vein occlusion in the right eye. Vabysmo has not been FDA-approved 
for use with retinal vein occlusion. The FDA has accepted the application to further evaluate but has not 
official approved its use for this condition. In addition, there is no Centers for Medicare & Medicaid Services 
(CMS)-approved support in its use as non-FDA for this condition.  
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 Vabysmo (J2777).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
8, 2023.  
You asked the Plan to waive the copayment for the ambulance services. You say that you were not able to use 
other forms of transportation. 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 $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 ambulance 
services provided on March 8, 2023.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the ambulance 
services. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact 
the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles shot provided on November 22, 2022. 
 
You asked the Plan to pay for the shingles shot. You say that you were unaware Shingles was a Part D benefit. 
The Plan denied your request. The Plan says the shingles shot isn't covered by our Plan. It may be covered by 
your prescription drug Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles shot. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles shot. 
Therefore, we decided that the Plan does not have to pay for the shingles shot provided on November 22, 2022.  
 
Benefits for the shingles shot may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 20, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic services. You say that you are appealing the claim. The Plan denied 
your request. The Plan says Rodney Writh is a non-network provider who does not work with the enrollee's 
health Plan. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided on February 20, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 14, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the enrollee is requesting reconsideration 
stating that COVID-19 restrictions reduced staffing and the ability to accumulate the documentation required to 
facilitate the submission of the appeal. The Plan denied your request. The Plan says they will maintain its initial 
determination to not provide payment for services that were not received within 12 months or 1 calendar year 
from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for wound care supplies was not filed until February 14, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for wound care supplies provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation. 
 
You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that the requested SI joint 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested SI 
joint radiofrequency ablation does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and 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 pre-approve SI joint radiofrequency ablation. Our 
reviewer says that the requested SI joint radiofrequency ablation is not considered medically necessary. Our 
physician reviewer found that this procedure is considered investigational because of the wide variation in 
efficacy published in the literature. Therefore, the request is deemed not medically reasonable and 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 SI joint radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve SI joint radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hereditary Cancer Syndrome panel testing (81307, 
81162, 81321). 
 
You asked the Plan to pre-approve the testing. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services 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 pre-approve the testing. Our physician reviewer 
found the provider has not established a diagnosis of cancer or found significant evidence to create suspicion 
for cancer in this enrollee. The documentation does not support that a Hereditary Cancer Panel is/was 
medically reasonable and necessary for the enrollee in this case.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hereditary Cancer Syndrome panel testing (81307, 81162, 81321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter lift for the car. 
 
You asked the Plan to pre-approve a scooter lift for the car. You say that you have a scooter, but you need the 
lift to get it into your car. You have no way to get to your doctor appointments without this lift. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve a scooter lift for the car.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the color guard makes your body 
sick.  The Plan denied your request. The Plan says the genicular nerve block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental and investigational 
procedure. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 15, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on November 15, 2022.
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 you are doing better in therapy and needs discharge 
planning done effectively. You say that your family needs to be trained effectually before you go home. The 
Plan denied your request. The Plan says you no longer had skilled nursing facility needs. 
 
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 you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network specialist visits provided on 
April 7, 2023, and April 27, 2023. 
 
You asked the Plan to waive the copayment for in-network specialist visits. You say that this provider is a 
family nurse practitioner (FNP), you should not have to pay a specialist copay for that, as they are not really a 
specialist. 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 $15 
copayment for physician/practitioner services, including office visits.  
 
You had two specialist visits, resulting in a $30 total copayment ($15 x 2 =$30).  
 You have been asked to pay a $30 total copayment for in-network specialist visits. This item/service falls 
within the physician/practitioner services, including 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 in-network specialist visits provided on April 7, 2023, and April 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cxbladder test. 
 
You asked the Plan to pre-approve the Cxbladder test. You say that the last cystoscopy was painful and had 
side effects after the test was done, and you decided to proceed with a urine test. The Plan denied your request. 
The Plan says the Cxbladder test is considered investigational and not covered by Medicare. 
 
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 Cxbladder test. Our reviewer says 
that the requested Cxbladder test.is not considered medically reasonable and necessary. Our physician reviewer 
found that the CxBladder test is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, 
possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. 
The current American Urological Association (AUA) guidelines do not recommend the CxBladder test for bladder cancer screening or monitoring. Urinary biomarker tests such as the CxBladder give significant false-
negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is 
poor for low-stage and low-grade tumors.   
 
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 Cxbladder test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Cxbladder test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support the medical 
necessity for LTACH admission. The Plan denied your request. The Plan says the enrollee's medical needs are 
being met in the current 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 there are no specific therapies that the enrollee obtains at the LTACH that are not 
currently being offered at the acute care hospital. 
 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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on February 03, 2023, to 
May 11, 2023.  
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment per date of service at outpatient hospital facility for outpatient surgery. There were 
eight dates of service. 8 x $350 = $2,800. Therefore, results in the total cost sharing amount of $2,800. 
 
 The enrollee has been asked to pay a $350 copayment per date of service for outpatient surgery. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient surgery on February 03, 2023, to May 11, 2023.