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

 
We decided that the Plan does not have to pay for inpatient admission services provided on January 1, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient admission services. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services rendered. 
 
 
 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 inpatient admission services provided on January 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time there is no 
contractual agreement between the laboratory and the dialysis facility which indicates that these services are 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
2, 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 IRF is the only setting to meet the enrollee's needs. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found in this case, the record indicates that the enrollee is scheduled for right knee arthroplasty. The record provided does not indicate that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors. The 
initial day may be spent in observation until it is clearly expected that a second midnight would be required, at 
which time the physician may order inpatient admission. The elements of the coverage criteria are not satisfied. 
The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: 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. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current acute setting, LTACH would add no additional services. 
 
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 medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the device will help with breathing. The 
Plan denied your request. The Plan says the device is being requested for use in a BiPAP mode. 
 
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 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 a home ventilator. Our physician 
reviewer found that you have chronic respiratory failure from chronic obstructive pulmonary disease. The 
provided documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. You could be treated with a BiPAP machine. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 enrollee is medically stable to be 
transferred out of the intensive care unit to an LTACH. You say that the enrollee deserves the best outcome to 
return to their prior level of function. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met at current hospital setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place which indicates that these services are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Ocrevus infusion provided on October 20, 
2022. 
 
You asked the Plan to reduce the coinsurance for Ocrevus infusion. You say that when you called for 
authorization, you were told the copayment would be $325. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. When Part B drugs are obtained in a providers office or 
outpatient setting, in- or out-of-network, the enrollees must pay 20% for each Medicare-covered Part B Drug. 
 
  You have been asked to pay $5,167.29, which is 20% of the allowed amount for Ocrevus infusion. The allowed 
amount is $25,836.45 (20% x $25,836.45 = $5,167.29). Ocrevus infusion falls within the Medicare Part B 
prescription drugs benefit category. The records show your maximum out-of-pocket was not met prior to this 
claim. 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 reduce the coinsurance for Ocrevus infusion provided on October 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vagus Nerve Stimulator (VNS) (64568). 
 
You asked the Plan to pre-approve a VNS. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a VNS have not been met. Specifically, the member does not have refractory partial onset seizures. 
Therefore, we decided that the Plan does not have to pre-approve a Vagus Nerve Stimulator (VNS) (64568).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no documentation that a different approach or medication will be utilized. 
 
The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection is only covered under 
certain medical indications.  
 
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 has chronic low back pain. He had a transforaminal ESI at the left L5 and left 
S1 levels on January 6, 2023. Documentation shows 80% improvement in his symptoms for the first few days 
then the pain gradually started returning. At his 2-week follow-up visit, the enrollee reported only having about 
30-40% improvement in his pain. A second repeat transforaminal ESI to be given at the same two levels, using 
the same approach, using the same steroid for injection was requested. The coverage criteria require a different 
approach after 14 days, or greater than 50% pain relief for 3 months. This was not achieved. Therefore, the 
request is deemed not medically reasonable and 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 an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
replacement monitoring will not impact medical management. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is only covered under 
certain medical indications. 
 
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 has a history of atrial fibrillation, with previous insertion of implantable loop 
recorder (ILR), now at the end of service. The ILR is being requested to allow continued monitoring of his 
atrial fibrillation. Based on current guidelines and the documentation provided, there is insufficient clinical 
evidence to support the medical appropriateness and necessity of replacing the old ILR with a new ILR. 
 
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 an implantable loop recorder (ILR).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI scan is medically necessary. The Plan 
denied your request. The Plan says the records do not show a 6-week trial of provider directed treatment. 
 
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 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the enrollee has low 
back pain and left-sided radiculopathy. It was reported that the enrollee had tried physical therapy (duration and 
timing of this treatment was not clearly documented). A computed tomography (CT) scan showed bulging disc 
with left lateral recess at L4-L5 corresponding to the left-sided radiculopathy. MRI lumbar spine was 
requested. However, the provided documentation did not clearly describe the treatments including physical 
therapy that was recently tried that was tried for at least 6 weeks in duration. Also, there was no recent physical 
examination findings showing worsening neuropathy or other red flag signs. Also, the CT scan showed 
evidence of stenosis already, identifying the area of concern. There were no formal plans for surgery to justify 
additional imaging. 
 
  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 a magnetic resonance imaging (MRI) of the lumbar spine without contrast.
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 your physician is recommending you go to acute 
rehabilitation. The Plan denied your request. The Plan says you do not have complex rehabilitation needs and 
require frequent rehabilitation doctor visits, medically necessary care may be provided safely in a different 
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. Our physician reviewer found the records do not show you to be able to tolerate fifteen hours per week of 
rehabilitative services with regular physician evaluation, your care needs can be met safely 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 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: 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 you are very sick and cannot swallow food which 
scares you because you live alone. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary. 
 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 daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport and ground mileage provided on August 25, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the medical records provided support the need for the requested ambulance transport. 
The Plan denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport and ground mileage.  Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital to the nursing home/assisted living facility/rehabilitation 
facility/residence was not medically necessary. The enrollee did not require the expertise of trained personnel 
or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could 
have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport and ground mileage provided on August 25, 2022.