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

 
We decided that the Plan does not have to pre-approve out-of-network chiropractic visits. 
 
You asked the Plan to pre-approve out-of-network chiropractic visits. The Plan denied your request. The Plan 
says in-network providers are available. 
 
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 
out-of-network chiropractic visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you need to see a specialist who 
specializes in lymphoma. The Plan denied your request. The Plan says there is an in-network provider that can 
perform the services you need. The Plan states they have approved a new office visit and a follow up with a 
contracted oncologist. 
 
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 office services 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 transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (CPT code 53854). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found the medical records provided do not show that the requirements listed in the LCD for Medicare coverage 
have been met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral destruction of prostate tissue; by radiofrequency generated water vapor 
thermotherapy (CPT code 53854).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs increased therapy for their 
medical needs and the IRF setting is more appropriate. The Plan denied your request. The Plan says the 
enrollee does not need an intensive program with a team of health care professionals and doctors that specialize 
in rehabilitation or the intense therapies in the acute rehabilitation setting. The enrollee's care could be provided 
in an outpatient, skilled nursing facility (SNF), or long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee's rehabilitation 
needs can be addressed in a SNF with similar outcome functionally. 
 
Documentation does not support necessity for admission to an IRF. While the enrollee may benefit from 
continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely provided 
in a lower intensity and alternate setting such as in a SNF. 
 
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 the IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing 
provided February 4, 2022. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing. You say that these 
tests were medically necessary. The Plan denied your request. The Plan says these tests are not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT and Heme CGP Panel testing are 
not FDA approved. Based on this information, we decided that Medicare rules for coverage of the requested 
testing have not been met.  Based on this information, we decided that Medicare rules for coverage of the 
Tempus xT Solid Tumor and Heme CGP Panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing provided February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel coded as 80050 provided on August 
27, 2020. 
 
You asked the Plan to pay for the general health panel coded as 80050. You say that you would like this claim 
reprocessed and approved for payment based on the services rendered. The Plan denied your request. The Plan 
says this code is not covered according to Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
coded as 80050 provided on August 27, 2020.
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 would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says they will continue to 
cover medically necessary care at the current facility until the enrollees condition is stable for transfer to an 
alternate level of care (such as a skilled nursing facility), or until the clinical circumstances change such that 
LTACH may be reconsidered. 
 
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 Opdivo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stave 
IVB metastatic castration-resistant prostate cancer. The Food and Drug Administration (FDA) has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
Opdivo is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Alimta. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of non-
small cell lung cancer (NSCLC). The record indicates that the requested regimen is being used as initial or 
induction therapy. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. The services are therefore not 
reasonable or medically 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 these services have not been met.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve Keytruda and Alimta.
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. The Plan denied your request. The Plan says there are no daily 
skilled therapy or 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 physician reviewer 
found that you were admitted to the hospital after a fall resulted in pain in the ribs. The most recent therapy 
documentation indicates you are able to ambulate up to 200 feet using an assistive device with contact-guard 
assistance. You require assistance for transfers. You are medically stable and do not have any complex daily 
wound care, parental medications or required care for a new or malfunctioning feeding tube. Your physical 
function is at or near your baseline. Therefore, an admission to a SNF for inpatient skilled rehabilitation 
services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (99213) provided on January 7, 2022. 
 
You asked the Plan to pay for the chiropractic service. You say that this service was medically necessary. The 
Plan denied your request. The Plan says insufficient information was provided to support this claim. 
 
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 chiropractic services (99213) provided 
on January 7, 2022. have been met. No medical records were provided to support the billed services. The plan requested additional records and none were received. Therefore, we decided that the Plan does not have to pay 
for chiropractic services (99213) provided on January 7, 2022.
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 February 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue were a 
medical necessity for the enrollee. 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 ESRD-related laboratory services provided on February 28, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Infliximab 10MG injection (CPT code J1745). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says that the records do not show that the enrollee has had a response from this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the Food and Drug Administration has stated that the requested drug is indicated for the enrollee's 
condition. The record indicates that the enrollee is in maintenance dosage phase and has no symptoms 
currently. The record provided establishes the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are satisfied. The requested service is 
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 the medication have been met. Therefore, we decided that the Plan has to pre-
approve Infliximab 10MG injection (CPT code J1745).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an above knee prosthesis with components (CPT 
code(s): L5624, L5321, L5631, L5649). 
 
You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is necessary. The Plan denied 
your request. The Plan says the clinical notes do not show a change in the physiologic condition, irreparable 
wear of the prosthesis or condition of the device or part of the device that requires repairs and that the cost of 
such repairs would be more than 60% of the cost of replacement. The Plan states you were seen for multiple 
prosthetic follow up visits; however, the notes do not show that the current prosthesis requires replacement. 
 
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 prosthesis. Our physician reviewer 
found the review has determined that the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an above knee prosthesis with components (CPT code(s): L5624, L5321, L5631, L5649).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate specific antigen test (PSA) received on 
 
You asked the Plan to pay for the PSA test. You say that your urologist recommended a second test. The Plan 
denied your request. The Plan says the service received exceeds your benefit limit. 
 
The Plan follows Medicare rules. The rules explicitly say that PSA testing is covered once every 12 months. 
 
 Review of the file shows that you received PSA testing on January 22, 2022. You previously received this 
testing on July 15, 2021. Twelve (12) months had not gone by in between these testing dates. This means you 
exceeded your benefit limit for this service. Therefore, we decided that the Plan does not have to pay for the 
prostate specific antigen test (PSA) received on
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not have the help you need at home. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that you require this therapy on an intensive IRF level. 
 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 IRF admission and services.