Persius/hicric huggingface dataset:
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 you are appealing on behalf of the 
enrollee, the preservice denial of LTAC. The Plan denied your request. The Plan says admission to LTACH 
was denied as not meeting criteria, not medically necessary, and continued acute hospital stay was offered, 
until the enrollee could discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with acute respiratory failure due 
to pneumonia and related to squamous cell cancer and recent right lobectomy with thoracostomy tube 
placement. The enrollee was treated with antibiotics and mechanical ventilation support. Trach and 
percutaneous endoscopic gastrostomy were placed. Recent notes describe the enrollee with log grade fever, 
encephalopathy not improving, still dependent on vent, but hemodynamically stable.  
 The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided on January 1, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that the 
copayment is too expensive. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $350 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation 
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 or reduce the 
copayment for ambulance transportation provided on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx genetic testing panel 
provided on February 20, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx genetic testing panel. You say that this testing 
was ordered by the treating physician to help with therapeutic decision making. This is a Medicare-covered 
test. The Plan denied your request. The Plan says the enrollee was previously approved for the FoundationOne 
CDx for tumor tissue profiling. There is no indication that the liquid version of the test is also required. There 
is tumor tissue available for this testing. 
 
 The Plan must follow Medicare rules. Medicare rules say that FDA-approved molecular diagnostic testing such 
as the test at issue in this case is covered when performed for an approved/cleared indication for use in the 
patient's cancer 
 
We looked at the file and Medicare rules. The enrollee is being evaluated for pancreatic cancer. The FDA 
approval for this testing is for use with non-small cell lung cancer and prostate cancer. Since this testing was 
not performed for an approved indication, the Medicare coverage criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne Liquid CDx genetic testing panel provided 
on February 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a dual-chamber automatic defibrillator. 
 
You asked the Plan to pre-approve implantation of a dual-chamber automatic defibrillator. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that defibrillators are covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implantation of a dual-chamber 
automatic defibrillator. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found you have a normal ejection fraction by recent echocardiogram. There is no evidence of a sustained 
ventricular tachyarrhythmia. As a result, at this time implantation of a dual-chamber automatic defibrillator 
would not be considered medically appropriate and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a dual-chamber automatic defibrillator have not been met.  
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve implantation of a dual-chamber automatic 
defibrillator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2022, billed with 
code 81479. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this provider has already been paid for genetic testing performed on 
this sample. Payment was previously made for codes 81162, 81292, 81295, 81298, 81317, 81194, and 81309 in 
the amount of $4993.44. No further payment can be made for this single code billed on a separate claim for the 
same testing. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing provided on 
February 8, 2022, billed with code 81479. have been met. Specifically, there is no documentation supporting 
that the services described by this single code are distinct from the services that were reimbursed by the Plan on 
a prior claim. Without clear documentation showing that code 81479 refers to a service that has not already 
been reimbursed, coverage for this code cannot be confirmed. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on February 8, 2022, billed with code 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), bifocal lens (V2200), and progressive 
lens (V2781) provided on March 29, 2022. 
 
You asked the Plan to pay for the glasses. You say that you got these new glasses because you recently had 
cataract surgery. The Plan denied your request. The Plan says your benefit maximum has been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers lenses and one pair of eyeglass frames or contact lenses every 2 years. 
 
We looked at the file and the Plan's rules. The record shows that you received frames and lenses on May 28, 
2021, and June 1, 2021. The record does not show that you had cataract surgery. Based on this information, we 
decided that the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames (V2020), bifocal lens (V2200), and progressive lens (V2781) provided on 
March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) facility. 
 
You asked the Plan to pre-approve the dialysis services. You say that you do not want to transition to a new 
facility. The Plan denied your request. The Plan says the services have been requested from an out-of-network 
facility and there is an in-network facility available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis services to be provided by an out-of-network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and cone 
beam imaging (D0383) provided on April 20, 2022. 
 
You asked the Plan to pay for an evaluation and imaging. You say that the provider never told you these 
services were not covered. The Plan denied your request. The Plan says a comprehensive periodontal 
evaluation (D0180) and cone beam imaging (D0383) are not covered by your routine dental benefits. 
 
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 pay for a 
comprehensive periodontal evaluation (D0180) and cone beam imaging (D0383) provided on April 20, 2022.
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 you are appealing the denied LTACH 
services with medical records. The Plan denied your request. The Plan says the enrollee's status is stable. The 
enrollee is receiving medically necessary care. The enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. The plan will continue to cover medically necessary acute and critical care at the current facility 
until the enrollee's condition is stable for transfer to an alternate level of care. 
 
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 that the enrollee appears to still be somewhat stable now and requires additional 
short-term acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be advantageous. Completion of 
treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
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 stay.
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 trips. You say that you have dialysis 3 times a week. The Plan 
denied your request. The Plan says the request would exceed your benefit limit. 
 
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 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The file shows that you have used 60 trips 
this year. 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has recurrent cancer and is not a 
candidate for chemotherapy. The Plan denied your request. The Plan says that the documentation does not 
support that the enrollee has an accepted medical indication for the use of Keytruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is FDA-approved for the enrollees diagnosis. Our physician reviewer found that the 
drug is approved for treatment of recurrent or metastatic cutaneous squamous cell carcinoma or locally 
advanced that is not curable by surgery or radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone tablet, 15 mg. 
 
You asked the Plan to pre-approve Oxycodone. You say that the requested drug is necessary for the enrollee. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 Oxycodone tablet, 15 mg.  
 Benefits for Oxycodone 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of extensive care, 
tube feeding, assistance with daily activities and getting out of bed. The Plan denied your request. The Plan 
says the enrollee's condition does not meet the requirements for approval and services can be provided in 
another 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 that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The medical record does not indicate that the enrollee requires services at 
the LTACH facility that they are not currently receiving. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
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 pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee has significantly decreased heart 
function. The Plan denied your request. The Plan says there are not enough studies to show that this device 
helps with the enrollee's condition. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found follow-up studies on CardioMEMS remain encouraging and suggest an improvement in heart 
failure symptoms with the use of the device. In addition, published expert opinion is supportive of the clinical 
usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies 
examining the long-term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at high risk for 
readmission. The Plan denied your request. The Plan says the enrollee is receiving the care needed in the 
current hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with a stroke. He suffered intracerebral 
hemorrhage and additional strokes. The record indicates that the enrollee has a pulmonary infection and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
 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.