Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says you do not show they have skilled nursing or therapy needs that need to be 
provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be 
received at a different setting, for example, home with home health, in residential care, or home with close 
follow-up with your doctor. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. Your wound care at this time is not complex. You do not have 
documented skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of your condition. Your care 
needs 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve purchased oxygen equipment.  
 
You asked the Plan to pre-approve the oxygen equipment for purchase. You say that it was more cost effective 
to purchase the equipment. The Plan denied your request. The Plan says purchased oxygen equipment is non-
covered. 
 
The Plan must follow Medicare rules. The rules say only rented oxygen equipment is eligible for coverage. 
Purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to 
pre-approve purchased oxygen equipment.
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 enrollee is ready for transfer to an IRF for 
remediation of skills in order to return home where she resides alone. The Plan denied your request. The Plan 
says the enrollee can receive the care needed at a skilled nursing facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for dizziness, nausea, and vomiting. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the documentation does support a need for physical and/or occupational therapy, there is no documented 
need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and coronavirus pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac catheterization (CPT code 93451) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says there are in-network providers that can render 
the services. 
 
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 
the cardiac catheterization (CPT code 93451) to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on June 3, 2021. 
 
You asked the Plan to pay for the rotary wing air transport and mileage. You say that the 911 emergency air 
transport does not require prior authorization, as taking time to obtain one could jeopardize the enrollee's safety 
in an emergency situation. The Plan denied your request. The Plan says the information provided does not 
support the criteria for air ambulance transport for chest pain and new diagnosis of a lung mass. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and mileage. 
Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the 
provided record does not indicate that the originating hospital was unable to provide care for the enrollee and 
no reason for transportation was provided. Our reviewer also found that the record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 rotary wing air transport and mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage 
(A0436) provided on June 3, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (81227, 81355) provided on March 8, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services 
were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the testing should be billed with one code. However, the 
Plan has overturned several of the codes on this claim for the testing in question. Without documentation 
supporting its denial of the remaining codes, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the lab services (81227, 81355) provided on March 8, 2021.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick external catheter system. 
 
You asked the Plan to pre-approve PureWick external catheter system. You say that it is medically necessary 
based on you having an overactive bladder. The Plan denied your request. The Plan says this is a convenience 
item that is primarily hygienic in nature and thus not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The PureWick catheter system is not a covered device and is not considered durable medical 
equipment. It is considered a convenience item that is primarily hygienic in nature and thus not covered. The 
item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to 
the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that 
the Plan does not have to pre-approve PureWick external catheter system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 23, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the POS code 81 ? indicating an independent lab setting ? is not 
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is 
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While 
a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for 
this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you feel additional time is needed 
to go over proper use of supplies after surgery. The Plan denied your request. The Plan says the denial of 
authorization for inpatient level of care is correct because you do not meet the requirements for inpatient level 
of care, but if medical issues develop this can be reconsidered. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our physician reviewer found the documentation submitted does not support the expectation that the 
enrollee will require a greater than 2 midnight stay. The enrollee is medically stable and has been provided 
medical clearance to undergo this elective procedure, which has been approved as an ambulatory 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pulse oximeter (E1399). 
 
You asked the Plan to pre-approve the pulse oximeter. You say that the medical record provided support the 
necessity of the requested service. The Plan denied your request. The Plan says this equipment is considered 
precautionary and is not covered under the DME benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the pulse oximeter (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic repetitive TMS treatment; subsequent motor 
threshold re-determination with delivery and management (CPT code 90869, therapeutic repetitive TMS 
treatment; initial, including cortical mapping, motor threshold determination, delivery and management (CPT 
code 90867), and therapeutic repetitive TMS treatment; subsequent delivery and management, per session 
(CPT code 90868), for the enrollee. 

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found in this case that the medical records provided for review do not readily support that the member meets 
the requirements of the LCD for coverage of TMS for depression. While the medical records stated that the 
member had a diagnosis of major depressive disorder (MDD), it was unclear how this diagnosis was made. 
There was no real discussion of the condition in the medical records provided for review. The records provided 
for review also did not support that the enrollee had a "trial of an evidence-based psychotherapy". Nor is it 
clear that the condition was resistant to pharmacotherapy (for depression) as required by the LCD. 
Furthermore, the order for TMS in this case was written by a neurologist whereas the LCD requires that: "The 
order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the patient and 
reviewed the record". Given the absence of psychiatry involvement with this case this requirement would also 
not have been met. For all of these reasons the requirements in the LCD have not been satisfied in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic repetitive TMS treatment; subsequent motor threshold re-determination with 
delivery and management (CPT code 90869, therapeutic repetitive TMS treatment; initial, including cortical 
mapping, motor threshold determination, delivery and management (CPT code 90867), and therapeutic 
repetitive TMS treatment; subsequent delivery and management, per session (CPT code 90868), for the 
enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 25, 
2020, to December 31, 2020. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
was not receiving any skilled services during this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility 
(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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from December 25, 2020, to December 31, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cancer Risk Panel provided on March 22, 2021. 
 You asked the Plan to pay for the Cancer Risk Panel. You say that this was a medically necessary test required 
for the enrollee's medical management. The Plan denied your request. The Plan says this is considered a 
screening test and is not among those covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
This test was ordered in the absence of signs or symptoms of cancer. The only reported diagnosis is a family 
history of cancer. This means that the test is deemed to be screening in nature and is not among the tests 
covered for this purpose. Therefore, we decided that the Plan does not have to pay for the Cancer Risk Panel 
provided on March 22, 2021.
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 have a bed sore, and the bed sore has 
gotten infected. You state you have tried three (3) different treatments, and nothing has been effective. You 
state you are not licensed, so you need a facility that specializes in wound care. You state you do not want to 
pass away from and infected wound from the bed sore. The Plan denied your request. The Plan says the 
services you need could be provided in another setting, such as an acute rehabilitation facility, skilled nursing 
facility, nursing facility, outpatient setting or home 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 you appear to be relatively stable and should only require short-term additional acute 
care services that can be safely administered at the current acute care facility until stable for a lower level of 
care to continue basic wound care. You do not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Therefore, LTACH services will be considered not medically necessary as 
transfer would not be clinically advantageous.  
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.