Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided from 
December 12, 2019, to February 6, 2020. 
 
You asked the Plan to pay for the inpatient psychiatric hospital services from December 12, 2019, to February 
6, 2020. You say that the services were medically necessary. The Plan denied your request. The Plan says the 
inpatient psych services were not necessary after December 11, 2019. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient psychiatric hospital services 
from December 12, 2019, to February 6, 2020. Our reviewer says that the service was not medically necessary 
after December 11, 2019. Our physician reviewer found based upon review of the records provided it was not 
expected this enrollee would improve in a reasonable period of time for the dates in question. The enrollee was 
described as being pleasant and cooperative, euthymic and calm. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the dates in question as the enrollee did not have dangerousness to self or others but was compliant 
with treatment. The health plans denial of continued inpatient psychiatric services is appropriate. It did not 
appear that the services were reasonably expected to improve the enrollees condition or for the purpose of 
diagnosis beyond the date in question. Based upon review the records provided for the admission of this 
enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in 
question of December 11, 2019 forward as this patient was not shown to be a danger to self or others.  
 
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 inpatient psychiatric hospital services from December 12, 2019, to February 
6, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
psychiatric hospital services provided from December 12, 2019, to February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 24 one-way 
transportation trips for the 2020 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the medical records support the need for 
SNF care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been 
met. The Plan says that the enrollee can continue to receive appropriate intensive rehabilitation services at the 
inpatient rehab facility until she is ready to safely return to the home or community-based environment. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and 
occupational therapy in the SNF. The enrollee was at maximal assist x2 for functional mobility, including a 
mechanical lift for transfers. The enrollee required varying assist with activities of daily living. The enrollee 
was treated for aphasia. There are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy services, but they are not required on a daily basis. The enrollee does not meet the severity of illness or 
intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 6, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
laboratory services. 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 laboratory services provided on July 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychiatric testing. 
 
You asked the Plan to pre-approve neuropsychiatric testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychiatric testing is only covered for certain 
indications. 
 
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 neuropsychiatric testing. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee carries a diagnosis of Mild Cognitive Impairment. The 
documentation shows this enrollee had a neurological evaluation for mild cognitive impairment, restless leg 
syndrome and radiculopathy. The enrollee's evaluation was found to be normal except for some forgetfulness. 
The criteria for Neuropsychological Testing from texts on the subject states that this testing is intended to 
diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly 
on the brain including detection of neurologic disease based on quantitative assessment of neurocognitive 
abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive 
effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central 
nervous system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders. The enrollee was evaluated for Mild 
Cognitive Impairment and was found to have a normal examination except for some forgetfulness. It does not 
appear medically necessary or reasonable to have neuropsychological testing performed on the enrollee as the 
criteria is not met. 
 
Review of the file shows that the plan uses Local Coverage Determination, LCD L34353 and L34646 to 
support their denial. LCD L34353 is not valid for the enrollees home state of New York and LCD L34646 is 
not valid for the enrollees home state of New York for Part B. Therefore, we cannot use LCD L34353 or 
L34646 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychiatric testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuropsychiatric testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 injections (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically necessary. Our physician reviewer found there is no documentation of first line drug 
failure with Orthovisc or Monovisc. Our reviewer also found that viscosupplementation injections have been 
shown to not be effective in recent literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 injections (J7328).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
  
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the requested test is 
medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has some coronary risk but no symptoms of dyspnea or chest pain 
concerning for ischemia, no documented cardiac exam abnormalities, and no ischemic appearing ECG changes.  
In this circumstance the documentation does not support the medical necessity for nuclear stress testing and 
coverage criteria above are not met since there are no documented covered indications for the 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 myocardial perfusion imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve myocardial perfusion imaging.
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 you need the service to recover and get 
well faster. The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary at this 
time. 
 
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 you do not require services at the LTACH that are not already available at the current 
setting. Our reviewer found that there are no services at the LTACH that you require that are not already 
available and covered at the current facility. Our physician reviewer also found that transfer to a lower level of 
care may be considered 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on February 5, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you were not 
aware prior authorization was required. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 the established patient office or other outpatient 
visit (99214) provided on February 5, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Salivary Pan Cancer Panel provided on February 6, 2020, 
to February 26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for Salivary Pan Cancer Panel. You say that you do not see the patient directly and 
that the specimen is sent to your office to perform testing. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 the Salivary Pan Cancer Panel provided on 
February 6, 2020, to February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve follow-up care with an out of network (OON) tertiary 
care provider. 
 
You asked the Plan to pre-approve the OON follow-up care. You say that you went to the emergency room on 
October 27, 2020, and the neurologist said that you have lesions on your brain. You say that you also had a 
spinal tap done and it showed critical areas. The Plan denied your request. The Plan says the enrollee is only 
entitled to a one-time second-opinion as a benefit. The Plan says that any follow-up care would depend on the 
results of the consult. 
  
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON follow-up care. Our reviewer 
says that the criteria for coverage of OON care have not been met. Our physician reviewer found there is 
nothing within the documentation provided to date that would indicate the follow-up care with an OON 
provider is necessary at this time. Rather, the enrollee has not yet seen the tertiary provider for a second 
opinion. The enrollee's issues mostly appeal to be ophthalmologic in nature, as neuroimaging has otherwise 
come back negative. There is no indication that the enrollee's ocular myasthenia gravis otherwise requires out 
of network care at this time. 
 
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 OON follow-up care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve follow-up care with an out of network (OON) tertiary care provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 17, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on May 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on May 8, 2020 to May 26, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 the physical therapy provided on May 8, 2020 to 
May 26, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 3, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
laboratory services. 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 laboratory services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided 
on May 19, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. 
 
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 the established patient assisted living visit (99336) 
provided on May 19, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada. 
 
You asked the Plan to pre-approve Erleada. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Erleada.  
 
Benefits for Erleada may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.