Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that your wound care needs can be appropriately performed in either 
the home or a non-skilled custodial extended care facility. 
 
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 services. Our reviewer says that 
SNF services are medically reasonable and necessary. You do have documented skilled nursing needs, in the 
form of daily wound care to multiple wounds. You do not have documented skilled therapy needs, as you are 
wheelchair dependent at baseline. Daily skilled services are required to establish a maintenance program or to 
prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare 
criteria for SNF services. 
 
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 services have been met. The Plan must continue coverage for the SNF 
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or 
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled 
nursing facility (SNF) services.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 24, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan denied your request. The Plan says that that there is a Local 
Coverage Determination (LCD) that indicates that any panel that tests for the FANCC gene is noncovered. 
Since this panel includes that, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication.  
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on February 24, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS system (L33289, 
C2624). 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for coverage 
have not been met because the requested service is experimental/investigational. 
 
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 a CardioMEMS system. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing 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 a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a CardioMEMS system (L33289, C2624).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services (97110, 97112) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you must receive your care from a 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 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 
physical therapy (PT) services (97110, 97112) to be provided by an out-of-network (OON) provider.
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 SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at an alternate level of care. 
 
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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. You do not have documented skilled nursing needs. 
You do not have documented skilled therapy needs. You are functioning at a level commiserate with your 
weight-bearing restriction. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, 
be provided at a lower level of care. Our physician reviewer found that your condition does not meet Medicare 
criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for a COVID-19 at-home test kit provided on April 16, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. The Plan denied your request. The Plan 
says that the COVID-19 at-home test kit is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022 people with Medicare Part 
B can get up to eight free over-the-counter COVID-19 tests. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a COVID-19 at-home test kit have been met. Therefore, we decided that the Plan has to reimburse 
you for a COVID-19 at-home test kit provided on April 16, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an annual wellness visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an annual wellness visit. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
an annual wellness visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the hospital is wanting you to move to a 
rehabilitation facility. You say that you want to be moved to the rehabilitation floor in the hospital. The Plan 
denied your request. The Plan says the requested services are not reasonable and 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 you were admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. Medically necessary care can be provided 
in a different 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (CPT code J3111). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you do not have any stated contraindications to the preferred products. The Plan 
states you have not tried any of the preferred agents and the provider does not provide a rationale for use of the 
non-preferred product for safety or efficacy. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Forteo before they will approve the requested drug. In this case, you have 
not tried and failed the required drug(s). There is no documentation provided indicating that the Plans required 
drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity (CPT code J3111).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen test. 
 
You asked the Plan to pre-approve the breath hydrogen test. You say that you are in a lot of pain. You say that 
your doctor determined this test is necessary for your health. You also say that you need proper treatment. The 
Plan denied your request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth (SIBO) and measuring small bowel transit time are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the breath hydrogen test have not been met. Specifically, the record indicates that the requested test 
is for diagnosing SIBO. Therefore, we decided that the Plan does not have to pre-approve a breath hydrogen 
test.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
outpatient mental health services to be provided by an out-of-network (OON) provider.
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 your needs can be met at an alternate level of care. 
 
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 does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for urinary tract infection. 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 medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sunosi 75MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Sunosi is a self-administered drug and does not fall under Part B coverage. 
 
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 Sunosi 75MG tablet.  
 Benefits for the medication 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 14, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Article (LCA) that 
indicates that a DEX Z-Code is required. 
 
We reviewed the LCA cited by the Plan but find that it is not applicable to the testing provided as the provider's 
billing state is Pennsylvania. This LCA is not valid for this state. As such, we disregarded the LCA cited by the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. The LCA cited by the Plan is not valid 
and no other valid denial rationale was presented by the Plan. Based on this information, we decided that 
Medicare rules for coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx (F1CDx) testing provided on February 14, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are appealing the denial of skilled 
nursing facility admission. The Plan denied your request. The Plan says medical necessity has 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 the SNF admission. Our reviewer says 
that the enrollee is medically stable and can receive further rehabilitation services at a lower level of care. Our 
physician reviewer found the enrollee is a 64-year-old male with a medical history including hypertension, 
diabetes mellitus with below the knee amputation, nephrectomy, urinary obstruction, cognitive impairment and 
previous urinary tract infection who was admitted to the hospital on June 29, 2022 after dislodging his 
nephrostomy tube. The enrollee has had several hospital stays for the same complaint and has been treated 
medically and has stabilized. The enrollee's prior level of function was that he had been residing in a private 
home with his family who helps him with self-care tasks and mobility. The enrollee uses a wheelchair for 
mobility. The most recent therapy documentation indicates the enrollee is at baseline physical functioning. The 
enrollee is medically stable and does not have any complex daily wound care, parental medications or required 
care for a new or malfunctioning feeding tube.  
 
The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare does not cover a wheelchair when the enrollee 
lives in a nursing home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a manual wheelchair.