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

 
We decided that the Plan does not have to pay for Guardant360 CDx (0242U) provided on September 27, 2021. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx 
have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 CDx (0242U) 
provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) Tooth #6, 14, 15, abutment supported porcelain/ceramic crown (D6058) Tooth #14, 15 and abutment 
supported retainer for porcelain/ceramic FPD (D6068) Tooth #6. 
 
You asked the Plan to pre-approve the dental services. You say that you need to have the services approved. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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. This benefit includes the 
requested D6057, D6058 and D6068 but is limited to up to two implants covered per year, or up to four 
implants covered per year for edentulous patients, covered one per tooth per life. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for custom fabricated abutment  includes placement (D6057) Tooth #3 
and 4, abutment supported retainer for porcelain/ceramic FPD (D6068) Tooth #3 and 4, and pontic - 
porcelain/ceramic (D6245) Tooth #5 from January 15, 2023, to April 22, 2023. Therefore, these benefits have 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment 
 includes placement (D6057) Tooth #6, 14 and 15, abutment supported porcelain/ceramic crown (D6058) 
Tooth #14 and 15 and abutment supported retainer for porcelain/ceramic FPD (D6068) Tooth #6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensors and Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensors and Reader. You say that you have been 
pricking your finger for more than 20 years. You also say that at the age of 79, it is still painful to prick your 
finger three times a day. The Plan denied your request. The Plan says you do not require insulin three or more 
times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 2 Sensors and Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensors and Reader.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for oncology provided on October 19, 2022. 
 
You asked the Plan to pay for oncology. You say that the services should be covered. The Plan denied your 
request. The Plan says that this was not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has failed to provide all appropriate documentation needed to render a 
decision. Therefore, we decided that the Plan has to pay for oncology provided on October 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported upper denture (D6110). 
 
You asked the Plan to pre-approve an implant. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported upper denture (D6110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test results inform treatment decisions. The 
Plan denied your request. The Plan says 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), sinus 
augmentation (D7951), custom fabricated abutment (D6057) and abutment supported crown (D6758). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your $2,500 annual maximum limit has 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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), sinus augmentation (D7951), custom 
fabricated abutment (D6057) and abutment supported crown (D6758).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing care provided on October 10, 2022. 
 
You asked the Plan to pay for skilled nursing care. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the enrollee generally must receive care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for skilled nursing care provided on October 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging Single Photon Emission 
Computed Tomography (SPECT) (78452). 
 
You asked the Plan to pre-approve SPECT testing. 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 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 SPECT testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Nuclear Myocardial Perfusion Imaging is not indicated for evaluation of mild tachycardia in an 
otherwise asymptomatic individual and the enrollee will not benefit from this test. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging Single Photon Emission Computed Tomography (SPECT) 
(78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have multiple chronic illnesses. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on December 06, 2022, to 
January 30, 2023, by an out-of-network (OON) provider. 
 
 
You asked the Plan to pay for psychotherapy visits. You say that the provider is in-network, and you would like 
to have the claim reprocessed and paid according to your benefits. The Plan denied your request. The Plan says 
the enrollee must receive their care from a network provider (for more information about this, see Section 2 in 
Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is not 
part of the plan's network) will not be 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 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 psychotherapy visits provided on December 06, 
2022, to January 30, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the item is not medically necessary. Our physician reviewer found there is no documentation 
in the medical record that the portable tanks are not meeting the patient's needs for mobility.  There is no 
documentation that the patient is able to maintain SpO2 greater than 91% during activity using an oxygen 
conserving device at a flow rate of 1 to 4 L/min. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that the enrollee is expected to have pain 
relief for a longer period of time with this procedure. The Plan denied your request. The Plan says the clinical 
value and effectiveness of this procedure have not been demonstrated. 
 
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 genicular nerve RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure. It is the subject of 
ongoing clinical trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 30, 2022, 
through April 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was admitted with worsening jaundice and pruritis. His total bilirubin was 24. He was 
admitted and treated with medical therapy including Ativan, Doxepin, Gabapentin and Cholestyramine. He was 
taken off Losartan. His condition stabilized and improved and he was discharged home with outpatient follow-
up on April 3, 2022. The review has determined that the record showed that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from March 30, 2022, through April 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0042T billed for date of service October 15, 
2022. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 042T is cerebral perfusion analysis using computed 
tomography (CT) with contrast administration, including post-processing of parametric maps with 
determination of cerebral blood flow, cerebral blood volume, and mean transit time. 
 We find that CPT code 042T is not supported in the medical record. Specifically, the records show that a CT 
angiography was provided. There is a more appropriate code available for the services provided. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 0042T billed for date of service October 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 2022, and from March 19, 2022, to April 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the admit date cannot be 
changed. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claims at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 2022, and from March 19, 2022, to April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs this device to breathe better. The 
Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on May 18, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that the urinary tract infection panel was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the panel testing provided on May 18, 2022.