Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit provided on May 20, 2021. 
 
You asked the Plan to pay for the specialist office visit. You say that there is a valid referral from the enrollee's 
primary care physician which states no authorization is needed. The Plan denied your request. The Plan says 
that the rendering provider is an out-of-network provider and there was no approved authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the specialist office visit by an in-network provider. The file does not show that 
the plan provided notice that the specialist office visit would not be covered. Under Medicare rules, this means 
the specialist office visit is considered approved by the plan. Therefore, we decided that the Plan has to pay for 
a specialist office visit provided on May 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
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 the services are not covered. 
 
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 these services is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be more stable and improving, tolerating weaning, and should 
require only short-term additional acute care services that can be safely administered at the current facility until 
more stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer may be considered when 
treatment has completed. 
 
 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 received oral medications, had stable vital 
signs and your lungs were clear. You had routine foley catheter care and a chronic dislocated hip infection. 
You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction, provided on December 8, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that the service should be covered. The Plan denied 
your request. The Plan says though the plan does have a supplemental policy, the eye refraction is only covered 
when given during a routine exam, and you did not have a routine exam, you had a medical exam due to your 
cataracts. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan's must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye refraction, provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PBT. 
 
You asked the Plan to pre-approve the PBT. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the notes show that the enrollee does not meet required criteria for PBT. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found proton beam therapy (PBT) is not medically reasonable and necessary in this case. There is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, intensity-
modulated radiation therapy (IMRT), brachytherapy with regards to safety and efficacy. The most recent 
American Urological Association (AUA) guidelines state that PBT offers no clinical advantage over other 
forms of definitive treatment. 
 
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 PBT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PBT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy with lesion removal, biopsy, and destruction 
of internal hemorrhoids by thermal energy provided on December 9, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a colonoscopy with lesion removal, biopsy, and destruction of internal 
hemorrhoids by thermal energy. You say that you did not obtain an authorization because the physician's order 
was showing a code, which did not need an authorization. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider involved in these services, and there is no referring provider 
involved in these services. The Plan also says that they did not authorize any services for this provider.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 a colonoscopy with lesion removal, biopsy, and 
destruction of internal hemorrhoids by thermal energy provided on December 9, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing for Myeloproliferative Disease- 
CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon (CPT code 
81219) and MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene 
analysis; sequence analysis, exon 10 (CPT code 81339). 
 
You asked the Plan to pre-approve the genetic testing. You say that the service is medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because your records do not 
show negative tests for BCR-ABL and JAK2. 
 
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 genetic testing. Our physician 
reviewer found the reviewed documentation indicates that you have abnormal blood tests concerning for 
myeloproliferative disease. The record sent by the provider does not show that you had negative tests for BCR-
ABL and JAK2. Medicare guidelines say that single-gene testing for MPL and CALR is only covered when 
BCR-ABL and JAK 2 mutation analysis were previously completed and negative. The review has determined 
that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing for Myeloproliferative Disease- CALR (calreticulin) (eg, 
myeloproliferative disorders), gene analysis, common variants in exon (CPT code 81219) and MPL (MPL 
proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, 
exon 10 (CPT code 81339).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, unclassified drugs, and prolonged evaluation 
and management (E/M) services provided on August 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, unclassified drugs, and prolonged evaluation and management 
(E/M) services. You say that as per credentialing status, the provider is enrolled and in-network with the Plan. 
You also say that services are payable, and the Plan is responsible to pay the provider. The Plan denied your 
request. The Plan says the rendering provider is a non-participating provider, and there is no referring provider 
involved in these services. The Plan also says that they did not authorize any services for this provider or 
facility. 
 
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 an office visit, unclassified drugs, and prolonged 
evaluation and management (E/M) services provided on August 25, 2021, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 9, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that the treatment provided to the enrollee was 
out of medical necessity and you would like the claim reprocessed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 physician services provided on November 9, 
2021, by an OON provider.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 
 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domicile Home Visit provided on November 30, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domicile Home Visit. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the services were not ordered or performed by an in-
network provider and there was an invalid or missing 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 Domicile Home Visit provided on November 30, 
2021 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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says an 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that contrary to the Plan's 
assertions and experimental and investigational labels, this devise has been embraced by clinicians nation-wide 
and recommended for stroke rehabilitation as the only available treatment for individuals with moderate to 
severe upper limb paresis. The Plan denied your request. The Plan says the medical records do not support 
medical necessity and whether this device meets but does not exceed your needs. The Plan also says that peer 
reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation to 
be investigational in nature with no long-term outcome data at this time. 
 
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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested MyoPro Motion G Orthotic device is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on 
scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. 
The MyoPro is not in widespread use based on scientific evidence. Our reviewer found that there is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, 
improve hemiparetic arm function, or be safe for long term use. Our physician reviewer also found that there is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mirror for scooter (K0108). 
 
You asked the Plan to pre-approve mirror for scooter. You say that you have plates and pins in your neck that 
prevent you from turning around to navigate well. The mirrors are medically necessary because you run into 
people and shelves and it can be dangerous for your safety. The Plan denied your request. The Plan says this 
item is a convenience item and does not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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. Based on this 
information, we decided that Medicare rules for coverage of mirror for scooter have not been met. Therefore, 
we decided that the Plan does not have to pre-approve mirror for scooter (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on February 1, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you have been going out of the area for 
years and the office visits have been covered before. You also called to find participating providers to the area 
you were traveling to. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no approved authorization. The Plan also stated they reviewed the claims history going back to 
2018 and there were no claims submitted when the enrollee was out of the area. Also, the service rendered was 
not urgent or emergent. 
 
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 a specialist office visit provided on February 1, 
2022, by an OON provider.