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

 
We decided that the Plan does not have to pre-approve a Lumber Spine w/dye Computed tomography (CT), 
lumbar spine; with contrast material 72132, Pelvis w/dye, and a Computed tomography (CT), pelvis; with 
contrast material(s) 72193. 
 
You asked the Plan to pre-approve a Lumber Spine w/dye Computed tomography (CT), lumbar spine; with 
contrast material 72132, Pelvis w/dye, and a Computed tomography (CT), pelvis; with contrast material(s) 
72193. The Plan denied your request. The Plan says the enrollee is currently under home hospice care. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service from March 18, 2023, through 
May 16, 2023, at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve a 
Lumber Spine w/dye Computed tomography (CT), lumbar spine; with contrast material 72132, Pelvis w/dye, 
and a Computed tomography (CT), pelvis; with contrast material(s) 72193.
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 an LTACH admission is necessary 
because you are not able to get up on your own, you need the assistance of at least 3 people, and you need to be 
weaned off a ventilator. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve the home health skilled nursing services. You say that you are in a 
wheelchair due to having one leg and was denied a prosthetic leg. You also say that you have a catheter and 
enlarged prostate and have no one to assist you when you travel to clinics. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 health skilled nursing 
services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the recertification order has not been signed. You do not have documented weekly skilled 
nursing needs. The notes state you require monthly Foley care. As such, the requested home health skilled 
nursing services are not medically necessary or reasonable. 
 
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 health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health skilled nursing 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 services are medically necessary. The Plan 
denied your request. The Plan says you are not eligible for skilled nursing facility admission coverage. 
 
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 require skilled nursing and skilled therapy services daily. You are 
medically stable and can receive further rehab services at a lower level of care. Although further rehab services 
would be appropriate to improve function, the intermittent skilled services can be provided at a lower level of 
care than a skilled nursing 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 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 pre-approve occipital radiofrequency ablation. 
 
You asked the Plan to pre-approve occipital radiofrequency ablation. You say that occipital radiofrequency 
ablation is medically necessary. The Plan denied your request. The Plan says the requested occipital 
radiofrequency ablation is not medically reasonable or necessary and is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve occipital radiofrequency ablation. Our 
reviewer says that the requested occipital radiofrequency ablation is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that occipital nerve blocks are considered standard of care 
but there are no randomized trials of radiofrequency ablation (RFA) that support its efficacy. Only 
conventional RFA is supported by CMS. 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 occipital radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve occipital radiofrequency ablation.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 19, 2022. 
 You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 7, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy. 
 
You asked the Plan to pre-approve speech therapy. You say that the enrollee needs speech therapy to 
effectively communicate with others during emergency scenarios for maximized safety and quality of life. The 
Plan denied your request. The Plan says speech therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 speech therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer that the enrollee has chronic speech impediment which has not responded to 
continued speech therapy. The enrollee can continue with a home program as therapy is not necessary to 
address their 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 speech therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve speech therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on September 
1, 2022.  
You asked the Plan to pay for hospital discharge day management. You say that the claim needs to be 
reprocessed. The Plan denied your request. The Plan says that Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided on September 
1, 2022.
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 being inpatient at a facility will have more time, 
space and equipment to assist you with getting your strength back. The Plan denied your request. The Plan says 
the services you require can safely be received at a different setting such as home with home health, in 
residential care, or home with close follow-up with your doctor. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do 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 and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Favorable

 
We decided that the Plan has to pay for services provided on June 28, 2022. 
 
You asked the Plan to pay for the medical services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan has not provided an argument.   
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support their decision. 
The Plan has not forwarded the claim or denial to indicate what was billed, when or why it was denied. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the Plan's decision has not 
been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for services 
provided on June 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aid batteries. 
 
You asked the Plan to pre-approve the hearing aid batteries. You say that you do not agree with the denial. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 hearing aid batteries have been met. The provider did not send the written order and clinical notes for the hearing aid batteries. Therefore, we 
decided that the Plan does not have to pre-approve the hearing aid batteries.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient admission from April 25, 2023, 
forward. 
 
You asked the Plan to pre-approve continued inpatient admission from April 25, 2023, forward. You say that 
this is medically necessary. The Plan denied your request. The Plan says this 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 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 admission from 
April 25, 2023, forward. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee was 
medically stable as of April 25, 2023. There was no indication for continued inpatient hospital services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient admission from April 25, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued inpatient admission from April 25, 
2023, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 16, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you are not sure what drugs were given to 
you at the time of the procedure. The Plan denied your request. The Plan says self-administered drugs does not 
fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on January 16, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. 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. 
 
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 Ilumya. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 7, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not know what procedure is being 
denied. The Plan denied your request. The Plan says self-administered drugs do not fall under Medicare Part B 
coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on December 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on December 14, 2022, to 
December 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this was not authorized. 
 
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 hospital care provided on December 14, 
2022, to December 16, 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 DecisionDx-SCC testing (0315U) provided on October 
17, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bathtub wall rail provided on August 14, 2022. 
 
You asked the Plan to pay for bathtub wall rail. You say that you would like reconsideration because the 
requested bathtub wall rail is medically necessary. The Plan denied your request. The Plan says the requested 
bathtub wall rail 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 pay for the bathtub wall rail provided on August 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair, percutaneous 
approach, including transseptal puncture when performed; initial prosthesis (TEER) (33418). 
 
You asked the Plan to pre-approve TEER. You say that this is medically necessary. The Plan denied your 
request. The Plan says your records do not show you have a cardiac surgeon as part of your care team. Your 
heart failure cardiologist has not documented your suitability for the procedure. 
 
The Plan follows Medicare rules. Medicare rules say that Transcatheter mitral valve repair can be covered 
when specific criteria are met. 
 
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 TEER. Our reviewer says that the 
enrollee has not been declared not a candidate for surgical repair by a cardiothoracic surgeon (heart team). 
Should the above missing information get provided, and the enrollee is declared at prohibitive risk of surgical 
intervention, Transcatheter Mitral Valve repair seems reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEER have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when 
performed; initial prosthesis (TEER) (33418).