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

 
We decided that the Plan does not have to pre-approve continuation of SNF care from April 8, 2022, forward. 
 
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 the stay is not medically necessary based on SNF 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 there are identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from April 8, 2022, forward.
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 the stay is not medically necessary based on SNF 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 there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing 
or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for 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 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 a ROMTech Portable Connect Device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered 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 a ROMTech Portable Connect Device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tumy Evo Swivel Seat. 
 
You asked the Plan to pre-approve these services. You say that the item will help you safely transfer out of 
your van. The Plan denied your request. The Plan says the item is 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 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 a Tumy Evo Swivel Seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
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 criteria for coverage are not 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 treat with 
insulin three or more times per day or use an insulin pump. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder arthroplasty (CPT code 23472) and the 
repair of biceps tendon (CPT cod 23430) to be provided by out-of-network providers. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee wants the right 
shoulder replaced and is eager to have it done as soon as possible as they would like to go to Mexico in the 
summer. The Plan denied your request. The Plan says the requested service is not urgent or emergent, and the 
enrollee should be re-directed to a contracted provider and 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 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 shoulder arthroplasty (CPT code 23472) and the repair of biceps tendon (CPT cod 23430) to be provided by 
out-of-network providers.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the most recent MRI results were not included. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags to 
mandate immediate MRI of the lumbar spine. In fact, there is no neurological exam in the enclosed records and 
no documentation of a six week trial of physical therapy. Absent such information, the medical necessity of 
MRI of the lumbar spine has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Medication assisted treatment provided on February 9, 2021 
to February 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Medication assisted treatment. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network visit. 
 
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 Medication assisted treatment provided on 
February 9, 2021 to February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate biomarker testing. 
 
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 criteria for coverage are not met.  
The Plan must follow Medicare rules. Medicare rules say that prostate biomarker testing is covered when 
specific criteria are met. 
 
We looked at the file and Medicare rules. The file shows that your prostate specific antigen (PSA) level is less 
than 3 mg/nL. 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 pre-approve prostate biomarker testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 75mg Gemtesa tablets. 
 
You asked the Plan to pre-approve the Gemtesa tablets. You say that you would like reconsideration because 
this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under 
Medicare Part B. 
 
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 75mg Gemtesa tablets.  
 
 Benefits for the Gemtesa tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair seat repairs (K0108). 
 
You asked the Plan to pre-approve the wheelchair seat repairs. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the service was requested using an incorrect code. 
 
The Plan must follow Medicare rules. Medicare rules say that miscellaneous code K0108 is not the correct 
code to use for billing wheelchair seat repairs. The correct codes to bill are: E0981 WHEELCHAIR 
ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH or E0982 WHEELCHAIR 
ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH. 
 
We looked at the file and Medicare rules. The service was requested using incorrect code K0108. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair seat repairs have not been met. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair seat repairs (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 / BRCA2 genetic testing (CPT code 81162). 
 
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 you have not had breast, ovarian, pancreatic or prostate cancer. The 
Plan states you have also had BRCA1 and BRCA2 testing previously in 2014, and for these reasons, the Plan 
will not cover these tests. 
 
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 review has determined that the medical records provided do not meet the requirements 
listed in the LCD for 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 BRCA1 / BRCA2 genetic testing (CPT code 81162).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), 
including computer-aided detection (CPT code 77049) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the MRI. You say that you have stage four (4) cancer and are having severe 
pain in your breast. You state you need the test to see if the cancer has spread. The Plan denied your request. 
The Plan says the records show that there is no medical need as to why you cannot get this imaging from a 
facility in your health plan's 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 
MRI, breast, without and with contrast material(s), including computer-aided detection (CPT code 77049) to be 
provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve An office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve An office visit. 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 are not medically necessary. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the enrollee has seen the out-of-
network provider prior for therapy and would not like switch to another provider. The Plan denied your request. 
The Plan says a list of in-network providers was offered to the enrollee that provide the same quality of service 
and is within the approved distance from the enrollee's residence. 
 
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 visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy visits.  
 
You asked the Plan to waive the copayment for occupational therapy visits. You say that you are on a fixed 
income and cannot afford the copayment. The Plan denied your request. The Plan says the copayment stands. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each occupational therapy or speech/language therapy visit regardless of the outpatient setting.  
 
You have been asked to pay a $30 copayment for each occupational therapy or speech/language therapy visit 
regardless of the outpatient setting. Occupational therapy visits fall within the Outpatient rehabilitation 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy visits.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH 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 improving and should only require short-term additional 
acute care services that can be safely administered at the current facility until more appropriate for a lower level 
of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is medically 
necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
average volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by 
bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to chronic obstructive pulmonary disease (COPD). 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  This enrollee has a diagnosis of asthma/COPD. 
Pulmonary function tests support a diagnosis of obstructive lung disease. There is no arterial blood gas (ABG) 
showing carbon dioxide (CO2) retention, so the enrollee does not meet criteria for a respiratory assist device. 
The enrollee's obstructive sleep apnea (OSA) appears to be adequately treated with CPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Physical Therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Physical Therapy. You say that requesting 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 
Physical Therapy to be provided by an out-of-network (OON) provider.