Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your 
request. The Plan says a lower level of care might be appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services in 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transportation and services provided on 
January 14, 2021. 
 
You asked the Plan to pay for the air ambulance transportation and services. You say that you paid out of 
pocket expenses to get the enrollee the services they needed. The Plan denied your request. The Plan says the 
enrollee was not transported to the nearest medical treatment facility. The Plan also says that transportation 
back to the United States from another country is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air ambulance transportation and services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance transportation and services provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022, billed with 
codes 81455, 81301, 81479, 81194, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 17, 2022, billed with codes 81455, 81301, 81479, 81194, and 81479.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olumiant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Olumiant.  
 
Benefits for these services 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on March 25, 
2022 to March 31, 2022 by an out-of-network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without 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 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 the outpatient mental health services provided on 
March 25, 2022 to March 31, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
03, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this transport was 
approximately a quarter of a mile, so you did not expect to receive such a large bill for such a short ride. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance transport. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. This copayment applies regardless of the distance of the transport. Therefore, we decided that the 
Plan does not have to waive the copayment for ambulance transport provided on February 03, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the member does not meet IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services 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 SelectMDx testing provided on May 5, 2022. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this testing can only be covered after an initial 
prostate biopsy, and there is no evidence that such a biopsy occurred. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as 
SelectMDx are subject to the MolDX application, assessment, and approval process. Once this is complete, the 
test is assigned a reimbursement rate and unique test identifier from the DEX Diagnostic Exchange. 
 
We looked at the file and Medicare rules. Per review of the DEX Diagnostic Exchange, the SelectMDx test was 
reviewed through the MolDX process and was found to not meet Medicare coverage criteria. Therefore, we 
decided that the Plan does not have to pay for the SelectMDx testing provided on May 5, 2022.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the member 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 in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services 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: 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 this admission is medically necessary for the 
member. The Plan denied your request. The Plan says IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services 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: 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 you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet Medicare 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 in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are functioning at a level amenable to repetitive exercise. Intensive therapy is not 
required and oversight from physiatry is 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 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 DecisionDX-SCS test provided on May 5. 2022. 
 You asked the Plan to pay for the DecisionDX-SCS test. You say that this claim was denied in error and this 
test is a covered benefit. The Plan denied your request. The Plan says this test is not covered for squamous cell 
carcinoma. 
 
The Plan follows Medicare rules. Medicare rules say that NGS tests are only covered for patients with 
advanced cancers when the test has FDA-approval for the specific indication for which it was ordered and 
when the test results will aid in the treatment of the patient.  
 
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 DecisionDX-SCS test. Our reviewer says 
that this test is not medically necessary. Our physician reviewer found use of molecular tests such as 
DecisionDx-SCC are not considered standard of care for determining treatment of squamous cell carcinoma. Its 
use is not supported by National Comprehensive Cancer Network (NCCN) Guidelines or the medical literature. 
Therefore, the enrollee does not meet the criteria for this testing. 
 
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 DecisionDX-SCS test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDX-SCS test provided on May 5. 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris MPI molecular intelligence profile test provided on 
May 23, 2022. 
 
You asked the Plan to pay for the Caris MPI molecular intelligence profile test. You say that it was the 
provider's responsibility to get the prior authorization.  It should not be your responsibility to pay for this due to 
their mistake. You said that you never received the Plan's authorization denial. The Plan denied your request. 
The Plan says this test does not have Food and Drug Administration (FDA) approval, so it is not covered.  
Authorization was denied prior to this service being rendered. 
 
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 pay for the Caris MPI molecular intelligence profile 
test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found you are a 73 year old male with Prostate cancer metastatic to the 
bladder. Caris Molecular Intelligence (CMI) is a multiplatform tumour profiling service that is used for guiding treatment options in patients with advanced cancer. Caris Life Sciences has been establishing a post-marketing 
registry with the aim to perform multicentre prospective observational studies to support an ongoing clinical 
outcome database. Caris Molecular Intelligence-tumor profiling and its derived implications upon treatment 
strategies are not changing treatment costs/cycle significantly. Taken together, the additional cost of 
performing CMI's multiplatform testing may be cost-effective due to high clinical utility and additional 
potential overall survival benefit associated with the test. Further randomized studies for evaluating the cost-
effectiveness of tumor profiling tests are needed to broaden access to such tests and enable discussions about 
reimbursement. Therefore, this test was not medically reasonable or 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 Caris MPI molecular intelligence profile test have not been met. Therefore, 
we decided that the Plan does not have to pay for the Caris MPI molecular intelligence profile test provided on 
May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 1, 2021, 
to November 3, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this diagnosis is 
appropriately cited in the medical record, so it was not appropriate for the Plan to downgrade the DRG and 
recoup payment. The Plan denied your request. The Plan says the billed secondary diagnosis of E43 
(unspecified severe protein-calorie malnutrition) is not supported in the medical record. Therefore, the DRG 
was downgraded, and additional payment was recouped for this admission. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis of E43 (unspecified severe 
protein-calorie malnutrition). 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 
services at the DRG originally billed. Our reviewer says that the secondary diagnosis of E43 (unspecified 
severe protein-calorie malnutrition) is not supported in the medical record. Our physician reviewer found the 
patient presented with chief complaint of chest pain. History and physical documents "He did endorse some 
recent unintentional weight loss but did not know how much or over what duration of time, only that "it goes 
up and down." The patient's body mass index (BMI) is documented to be 25.39. The discharge summary states 
BMI 15.33 which is incorrect. There is no treatment evident in the documentation and no Registered dietitian 
consult. The patient remained on a regular diet during the admission. Therefore, the secondary diagnosis of E43 
(unspecified severe protein-calorie malnutrition) was not supported in the medical record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from November 1, 2021, to November 3, 2021, at the Diagnosis 
Related Group (DRG) originally billed.