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

 
We decided that the Plan does not have to pre-approve an upper endoscopy.  
 
You asked the Plan to pre-approve an upper endoscopy. You say that an upper endoscopy is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for an upper endoscopy.  
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 an upper endoscopy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available medical record show a diagnosis of multifactorial anemia but no evidence of GI 
blood loss. Anemia has improved with oral iron supplementation. The LCD coverage criteria for EGD require 
that colonoscopy first prove negative. This requirement has not been met. Therefore, Medicare coverage 
criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of an upper endoscopy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an upper endoscopy.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee is with a history of stage IV colon cancer who was admitted to the current acute care hospital with 
abdominal pain. She was diagnosed with pancreatitis and had been recently been receiving chemotherapy. She 
is being recommended hospice care by multiple treating physicians due to her poor prognosis and her not being 
a candidate for surgery for the obstruction and pancreatitis. 
 
The enrollee appears to not be a candidate for long term acute care services. The enrollee does not require 
services at the LTACH that are not available at the current facility or lower level of care facility. There are no 
services at the LTACH that the enrollee requires that are not already being provided and covered at the current 
facility. Therefore, as there would be no advantage to transferring to LTACH at this time, the LTACH services 
will be considered not medically 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee had both knees replaced 
on 7/16/19 with periprosthetic left tibia fracture and ongoing left knee pain. From a nursing perspective, the 
enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. 
Regarding rehabilitation services, the enrollee received physical therapy in the home setting, most recently in 
1/2020.  At that time, she was at a modified independent to stand by assist level with functional mobility 
including gait to 75 feet.  She remained non-weight bearing to her left lower extremity. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not have 
documented skilled therapy needs.  The enrollee appears to be functioning at/near his baseline.  The enrollees 
care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular 
physician evaluation.  The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation as to whether or not there has been a sleep survey, daytime 
sleepiness, witnessed sleep apneas or snoring. 
 
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found  
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #19 to be provided by you, an OON 
provider. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says you are an OON 
provider. The Plan also says that services provided by an OON or non-contracted provider are not provided 
under the dental benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
crown for tooth #19 to be provided by you, an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions of all teeth. 
 
You asked the Plan to pre-approve the extractions. You say that the enrollee needs extractions prior to having a 
heart valve replacement. The Plan denied your request. The Plan says extractions are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the 
extractions of all teeth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence wipes. 
 
You asked the Plan to pre-approve incontinence wipes. You say that you have a urinary tract infection and need 
the incontinence wipes to be approved. The Plan denied your request. The Plan says common household and 
personal hygiene items generally used by the public, including but not limited to washcloths, wet wipes, and 
non-sterile swabs are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic decompression of the spinal cord 
(62380). 
 
You asked the Plan to pre-approve an endoscopic decompression of the spinal cord. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 an endoscopic decompression of the 
spinal cord. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is 
needed to show that it is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoscopic decompression of the spinal cord have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an endoscopic decompression of the spinal cord (62380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infrared light therapy device. 
 
You asked the Plan to pre-approve an infrared light therapy device. You say that you need an infrared light 
therapy device to use at home for your condition. The Plan denied your request. The Plan says Medicare does 
not cover special heating pads. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of an infrared light therapy device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an infrared light therapy device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The 
enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
January 10, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing and should be 
paid. The Plan denied your request. The Plan says there is no valid order for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. 
 
The file contains an unsigned order for a custom panel. There is no documentation to indicate what is included 
in the custom panel. The progress note does not offer sufficient detail to support the intent to perform the billed 
testing in this case. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive 
drug testing provided on January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 14, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that this was an extension of an initial visit provided by the 
referring provider. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan 
says that the referring provider is out-of-network. 
 
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 has network providers 
available who can provide 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 lab work provided on January 14, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 19, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the documentation does not include a 
valid physician order, lab requisition, or medical records stating exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on February 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered from February 19, 2019 to 
February 23, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered from February 19, 2019 to February 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on January 30, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 skilled nursing services provided on January 30, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the 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 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 physician's services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusionist services provided on April 14, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup 
and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says 
services to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. This service was provided via 
arrangement of the facility. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility. 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 
the perfusionist services provided on April 14, 2020.