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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the increase of 
physical therapy that only the LTACH can provide. The Plan denied your request. The Plan says the records 
show that the enrollee can continue to get the care they need in the current hospital setting and when they are 
ready to leave the hospital, they can safely receive the care they need in another setting like a skilled nursing 
facility. 
 
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 appears to be improving and should only require short-term 
additional acute care services that can safely be 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 the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the service assures complete removal of 
the tumor. The Plan denied your request. The Plan says daily imaging is not 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 the requested services. Our physician 
reviewer found that radiation is a standard approach to the treatment of skin cancer and is often preferred over 
surgery when resection is likely to result in unacceptable morbidity or cosmesis. However, the treatment itself 
is not disputed in this case but rather the need for image guidance. Certainly, using ultrasound on a daily basis 
is not unreasonable to offer but not necessary. To bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines is 
not necessary.  Daily simulations would not be furnished in accordance with accepted standards of medical 
practice. 
 
 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 ultrasound guided radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 nursing facility care provided on April 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from April 19, 2022, to 
April 23, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like this bill to be resolved. 
The Plan denied your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from April 19, 2022, to April 23, 2022.  
 
Benefits for the self-administered drugs 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: 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 enrollee requires intensive therapy so they can be 
discharged from the facility to their prior living situation. The Plan denied your request. The Plan says that 
based on the records received the enrollee does not meet the criteria for IRF admission and the enrollee can 
receive the care they need in another facility like a skilled nursing 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 clinical documentation by the primary team specifically states that intense 
therapy is unlikely to help with significant functional gain and recommends long term care. Additionally, there 
is no IRF compliant rehabilitation diagnosis or documentation to support inpatient hospitalization with close 
medical monitoring during rehabilitation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 member does not require and cannot benefit from intensive rehabilitation as she 
has an uncomplicated hip fracture and impaired weight bearing status. Our physician reviewer also found that 
the member does not require frequent physiatry oversite. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laser surgery provided on January 26, 
2022, by an OON provider. 
 
You asked the Plan to pay for an office visit and laser surgery. You say that you do not agree with the denial. 
The Plan denied your request. The Plan says you must receive your care from a network provider. The out-of-
network services were 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 an office visit and laser surgery provided on 
January 26, 2022, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on October 18, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this claim is excluded from consolidated 
billing. You also say that the enrollee was transported for emergency services. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. 
The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 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 the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on June 21, 2022, by an 
OON provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you were told this was a routine exam 
and acceptable in most cases. You say that you have been going to this provider for years and do not wish to 
make a change. The Plan denied your request. The Plan says the supplemental vision plan covers only in-
network providers. 
 
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 ophthalmological services provided on June 21, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on May 6, 2022. 
 
You asked the Plan to pay for the perfusion services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services are included in payment 
made to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
The file shows that the enrollee was an inpatient at the time the services were provided. The facility must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers. These services were provided via arrangement of the facility. Payment for these services would have been included under the facility claim. Payment for these services is the responsibility of the 
facility. Based on this information, we decided that Medicare rules for coverage of the perfusion services have 
not been met. Therefore, we decided that the Plan does not have to pay for the perfusion services provided on 
May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has a current diagnosis of chronic 
hypercapnic respiratory failure with most recent hospitalization of carbon dioxide level greater than 13. The 
Plan denied your request. The Plan says the requested device does not meet the requirements for approval. 
 
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 ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has was 
admitted with hypercapnic respiratory failure in the of chronic obstructive pulmonary disease. The record 
indicates that the enrollee was successfully treated with BiPAP. The provided primary source documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. The 
enrollee could be treated with a BiPAP machine. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services coded as 97112, G0283, J3420 and J3475 provided 
to the enrollee on March 31, 2022. 
 
You asked the Plan to pay for codes 97112 and G0283. We note the Plan previously paid codes J3420 and 
J3475. You say that this claim should be paid. The Plan denied your request. The Plan says that while a portion 
of this claim was paid, the enrollee did not have prior authorization for out-of-network care and the records 
provided do not support the services billed. 
 
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.  The Plan cannot pay for half of the claim and also deny half of 
the claim for both out-of-network reasons and lack of supporting records submitted. The Plan has not made a 
clear determination on their denial of this case. Therefore, we decided that the Plan has to pay for physician 
services coded as 97112, G0283, J3420 and J3475 provided to the enrollee on March 31, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary. Our physician reviewer found the 
documentation shows that you have an IRF compliant diagnosis and multiple active comorbidities of such 
complexity that would require close medical monitoring with an acute inpatient stay during rehabilitation. You 
are beneath functional baseline and require three disciplines of therapy (physical therapy, occupational therapy 
and speech therapy) and all evaluating therapists specifically recommend an intense therapy regimen, thus IRF 
criteria have been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiogram. 
 
You asked the Plan to pre-approve a stress echocardiogram. You say that a stress echocardiogram is medically 
necessary. The Plan denied your request. The Plan says the requested stress echocardiogram does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve a stress echocardiogram. Our reviewer 
says that a stress echocardiogram is not medically necessary. Our physician reviewer found that the enrollees 
pre-test probability for an abnormal test is low and there is no documentation that the ECG shows an 
uninterpretable pattern. There is no evidence provided that would support the need for stress echocardiography. 
In summary, there is insufficient documentation to support the medical necessity for the requested stress 
echocardiography in this enrollees clinical management. 
 
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 stress echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stress echocardiogram.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of bone marrow aspirate is 
considered experimental in nature. More research is needed to show safety and efficacy when used as bone 
graft material. 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 bone marrow aspirate.
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 the requested service. You say that the ventilator will help the enrollee in 
their disease process. The Plan denied your request. The Plan says settings that could be delivered by 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 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 requested service. Our physician 
reviewer found that the enrollee has a medical history of chronic obstructive pulmonary disease. The records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device. Claims for ventilators 
used to provide CPAP or bi-level PAP therapy will be denied as not 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 service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.