Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of an ongoing inpatient psychiatric 
admission from August 9, 2022, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are 
medically necessary and court-ordered. The Plan denied your request. The Plan says as of August 9, 2022, the 
enrollee no longer requires the intensity of care provided in an inpatient psychiatric setting and can be treated 
in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continued inpatient psychiatric care. 
Our reviewer says that the health plan's denial of continued inpatient psychiatric services appears appropriate in 
this case. Our physician reviewer found  
 
that this enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on August 2, 
2022, with Schizoaffective Disorder, Depressed Type, Chronic Posttraumatic Stress Disorder, Generalized 
Anxiety Disorder and Insomnia. Based upon a review of the records provided, it was not expected this enrollee 
would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations and was without aggressive behaviors while 
not showing any acute threats of safety. The enrollee reported feeling safe in the hospital setting and is worried 
about his safety out the community. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the enrollees 
condition or for the purpose of diagnosis. Based upon review the records provided, the enrollee does not meet 
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 9, 
2022, forward and could have been treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continuation of an ongoing inpatient psychiatric admission from 
August 9, 2022, forward.
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 you need to be moved to an SNF for continued 
therapy. The Plan denied your request. The Plan says the criteria for admission to an SNF are not met as you do 
not have any daily skilled nursing needs. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing needs which require the specialized 
skill, knowledge and judgement of a professional skilled nurse. You do not have documented skilled therapy 
needs which require the specialized skill, knowledge and judgement of a qualified therapist. You are 
ambulating more than 100 feet. 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 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
January 10, 2022. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. 
 Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
rendered on January 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 111 miles of ground mileage (A0425) 
provided on April 2, 2021. 
 
You asked the Plan to pay for the additional 111 miles of ground mileage. The Plan denied your request. The 
Plan says there are no medical records provided indicating that closer rehabilitation facilities were not 
appropriate to care for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the additional 111 miles of ground 
mileage (A0425) provided on April 2, 2021. have been met. Specifically, the Plan made several attempts to 
obtain a full run report of the ambulance transportation provided on April 2, 2021, but no documentation was 
provided. Without this information, we cannot determine if the facility that was within 10 miles of the facility 
the enrollee was transported from was unable to provide adequate care. Therefore, we decided that the Plan 
does not have to pay for the additional 111 miles of ground mileage (A0425) provided on April 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9131 billed for date of service February 28, 
2022 to March 3, 2022. 
 
You asked the Plan to pay for procedure code S9131. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9131 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9131 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9131 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9131 billed for date of service February 28, 2022 to March 3, 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 you want to get out of your wheelchair. You also say 
that you do not want to be in the wheelchair for the rest of your life. The Plan denied your request. The Plan 
says based on Medicare guidelines, the IRF services being requested do not meet the requirements for 
approval. 
 
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 no acute rehab nursing needs identified or documented. Our physician reviewer also 
found that at the current functional level, the enrollee does not need intensive therapies consisting of at least 
three hours of therapy per day at least five days per week with multidisciplinary approach 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient consultation with a non-plan provider. 
 
You asked the Plan to pre-approve the outpatient consultation. You say that you have established a relationship 
with, and are familiar with, the requested provider. You also say that you are unable to drive out of town for 
services because you have no transportation. The Plan denied your request. The Plan says the available medical 
information does not support the need for an authorization to a non-plan provider. The Plan also says that 
services are available with plan providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve an outpatient consultation with a non-plan provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan of the whole body 
(78813). 
 
You asked the Plan to pre-approve a PET scan. You say that you have been suffering for two and a half years 
from a fever of unknown origin. You also say that you would like this PET scan to be approved for coverage. 
The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that a 
PET scan is medically reasonable and necessary. Our physician reviewer found you are medicated with steroids 
and Imuran, which places you at risk for a variety of opportunistic infections. Your fever has worsened 
reaching 102 degrees Fahrenheit. Our reviewer found that you have had prior computed tomography (CT) 
workup. Our physician reviewer also found that based upon your rising fever, medication history, and negative 
CT workup, a PET/CT is the last and most reasonable imaging test to try to attempt to locate a source of your 
fever. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan of the whole body (78813).  
 
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: 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 are requesting LTACH services to 
bring the enrollee to the next level of care. 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil. 
 
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 Sildenafil.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and was not 
performed to a hospital inpatient. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 21, 2022.
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 are unable to recover in any other 
setting, therefore you are requesting LTACH services. 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where you are 
currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
procedure has not been found to be helpful for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee is being treated for radiculopathy of the cervical region. The Plan has agreed to 
pre-approve the inpatient admission and cervical fusion. However, there is no specific indication provided to 
support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in 
conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of bone marrow aspirate for this enrollees medical condition. Therefore, the 
requested bone marrow aspirate during approved cervical fusion surgery, in this case, is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria (Q5122). 
 
You asked the Plan to pre-approve Nyvepria. The Plan denied your request. The Plan says this request does not 
meet the Part B step therapy criteria for the requested drug. 
 
  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 Nyvepria. Our reviewer says that 
Nyvepria is not reasonable and necessary. Our physician reviewer found there is no indication that the patient 
has tried and failed the required drugs, Neulasta (Pegfilgrastim) or Fulphila (Pegfilgrastim-jmdb). Our reviewer 
also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria (Q5122).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool. 
 
You asked the Plan to pre-approve a tub stool. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a tub stool may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a tub stool.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 15, 2022, to March 16, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a Notice of 
Admission (NOA) is required in order to process the final claim. The documentation shows that the provider 
submitted an NOA with a date of service of February 15, 2022, but in the final claim, the admission date is February 14, 2022. This means the dates do not match. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from February 15, 2022, to March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a therapeutic CGM and related supplies.