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

 
We decided that the Plan does not have to pay for a home health visit provided on November 23, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on November 23, 
2021, by an OON provider.
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 cannot care for themself to 
be at a skilled nursing facility or any lower level of care. You state LTACH level of care would give the 
enrollee the best care for clinical improvements. The Plan denied your request. The Plan says the stay is not 
medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. 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 he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for targeted genomic sequence analysis panel (81455) provided on August 
9, 2021. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that you would like this 
claim reprocessed based on medical necessity. The Plan denied your request. The Plan says that genetic testing 
procedures submitted with code 81455 are unlikely to impact therapeutic decision making in the clinical 
management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for targeted genomic sequence analysis panel. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of next generation sequencing (NGS) is recommended by the 
National Comprehensive Cancer Network Guidelines once a Myeloproliferative neoplasms diagnosis is 
confirmed NGS is recommended for mutational prognostication. According to bone marrow results this patient 
has a myeloproliferative disorder. The use of NGS was reasonable and 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 targeted genomic sequence analysis panel have been met. Therefore, we 
decided that the Plan has to pay for targeted genomic sequence analysis panel (81455) provided on August 9, 
2021.  
 
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 additional rental months for an Oxygen Concentrator 
and a Portable Oxygen System. 
 
You asked the Plan to pre-approve additional rental months for oxygen equipment. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has exhausted the 
36-month rental benefit. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The file shows that the enrollee has used all 36 months of the covered 
rental for oxygen equipment. 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 additional rental 
months for an Oxygen Concentrator and a Portable Oxygen System.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says that a sleep study 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a sleep study. Our reviewer says that 
the requested sleep study is considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the clinical documentation describing classic symptoms of obstructive sleep apnea (OSA), it 
did not match the previous sleep study results from 2012 and deserves a repeat study to try to confirm this 
diagnosis of OSA, which is likely so you can get the treatment you need. Therefore, this request for a sleep 
study will be considered 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 a sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a sleep study.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112) and the therapeutic 
exercises (97530) rendered by the out-of-network (OON) provider on December 8, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the neuromuscular reeducation (97112) and the therapeutic exercises (97530) 
rendered by the out-of-network (OON) provider on December 8, 2021.
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. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 patient is a 71-year-old female who was admitted to the acute care hospital with 
squamous cell carcinoma or oral cavity status post wide local excision buccal space complicated by requiring 
tracheostomy and percutaneous endoscopic gastrostomy placement. She was treated with tube feeds, 
antibiotics, neck drains. Recent notes describe the patient as now tolerating trach collar with low dose oxygen support and tube feeds. Wound care needs are not complex. The patient appears to be more stable and 
improving and should only require short-term additional acute care services that can be safely completed at the 
current facility until more appropriate for a lower level of care. The patient 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 
patient requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Transfer to a lower level of care 
may be considered when treatment has completed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
November 15, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was 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 pay for the inpatient hospital care. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation describes the patient as hemodynamically stable, without 
chest pain or other symptoms, and appropriate for a lower level of care beginning January 12, 2022, as only quarantine was needed following this date which could have been completed at home. Therefore, the continued 
inpatient stay from January 12, 2022, will be considered 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 the inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below his 
baseline. Daily skilled services are required to establish a maintenance program or to prevent deterioration of 
the enrollees 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. You appear to be functioning below your baseline. The 
documentation does not establish that you have reached a plateau in function.  Daily skilled services are 
required to establish a maintenance program or to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. Daily skilled services are required to 
establish a maintenance program and/or to prevent deterioration of the enrollees 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pay for the acute inpatient hospital care provided from November 19, 2021, to 
November 29, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the denial of payment for inpatient level of care is 
correct, because this was not medically necessary, and care could have been provided at a lower level such as 
observation. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department on November 19, 2021 and was admitted 
and treated with medical therapy. The enrollee's condition stabilized and improved, and the enrollee was 
discharged home on November 29, 2021, when considered medically stable. At the time of inpatient admission, 
the admitting physician reasonably expected that the enrollee's necessary hospital care would span at least 2 
midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 19, 2021, to November 29, 2021.  
 
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.