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

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that none of the in-network providers were 
answering. The Plan denied your request. The Plan says a list of multiple in-network providers was giving to 
the enrollee that are accepting new patients. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee is 
unlikely able to participate in an intensive therapy program. 
 
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 physician reviewer found 
that the enrollee was admitted to home health due to weakness and multiple falls. The enrollee is bed to chair 
with maximal assist, and requires a walker for ambulation of 20 feet, and transfers.  The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation 
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not 
clear that the enrollee in this case will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. The documentation does not support that the enrollee requires at least 3 
hours a day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require supervision by a rehabilitation physician. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for respiratory failure. She is at a standby assist level 
for standing up and at contact guard assist for walking using a rolling walker. The enrollee does not require the 
intensity of services provided at an IRF.  Specifically, she is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet 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 the enrollee is receiving appropriate care at the present acute care hospital. 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional chest x-ray provided to the enrollee on 
September 25, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest; single view." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found a review of the submitted medical 
records reveals a single chest x-ray done on 9/25/21 and interpreted by the physician on 9/25/21 and signed at 
13:06. The records do not show a second chest x-ray done on the date in question. 
 We looked at this coder'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 pay for an additional chest x-ray provided to the enrollee on September 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided the Plan does not have to pay for oxygen equipment purchased out of network on February 22, 
2021. 
 
You asked the Plan to pay for this equipment. You say that this equipment should be paid for by the Plan. The 
Plan denied your request. The Plan says oxygen equipment is only covered when rented and not purchases. In 
addition, you did not have prior authorization for this purchase. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment requires prior authorization. This type of rented equipment is not allowed for 
purchase under the Plan contract. You did not have prior authorization.  
 We found no exception that would require the Plan to pay for this equipment. Therefore, we decided that the 
Plan does not have to pay for an oxygen concentrator purchased out of network on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you use the compression stockings 
for venous insufficiency. You are unable to remove the previously prescribed stockings without assistance and 
you feel this should be covered. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the requested admission is medically 
necessary. The Plan denied your request. The Plan says there are no signed orders for daily skilled services that 
can only be provided on an inpatient basis in a skilled nursing facility (SNF). 
 
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 a skilled nursing facility (SNF) 
admission. have been met. Specifically, the file does not include records to support the need for daily skilled 
services. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automated blood pressure cuff (A4670). 
 
You asked the Plan to pre-approve an automated blood pressure cuff. You say that you like to check your blood 
pressure at home and did not have luck with the manual one. You would like to have this approved since you 
have congestive heart failure and is on oxygen 24/7. The Plan denied your request. The Plan says an automatic 
blood pressure cuff is not a covered under the Plan benefits. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automated blood pressure cuff (A4670).
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. you do not require at least 
3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. You can participate in 
therapy at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is still having pain The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has a history of chronic neck pain due to cervical spondylosis. He has been 
treated with medical therapy and cervical trigger point injections. He underwent diagnostic cervical facet 
injections. In this case, the diagnostic facet injections were performed, however, the enrollee did not achieve 
greater than 50% improvement. The review has determined that the coverage criteria 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
February 28, 2022, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the requested 
continuation of inpatient mental health care from February 28, 2022, and forward is medically necessary. The 
Plan denied your request. The Plan says the requested continuation of inpatient mental health care from 
February 28, 2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  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 continuation of inpatient mental 
health care. Our reviewer says that the requested continuation of inpatient mental health care from February 28, 
2022, and forward is not medically necessary. Our physician reviewer found this enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in 
question. I am unable to find an individualized treatment plan however the entire record is not present. It did 
appear that the records were supervised and evaluated by a physician. Based upon review of the records 
provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the 
dates in question of February 28, 2022, and forward as this enrollee was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with 
treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats 
of safety. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
February 28, 2022, and forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ADmark Early Onset Alzheimer's genetic 
evaluation. 
 
You asked the Plan to pre-approve the ADmark testing. You say that this testing is medically necessary to 
assess the enrollee's risk of Alzheimer's disease. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the Athena Lab Panel in the setting of cognitive dysfunction outside of a clinical trial have 
not been demonstrated in the peer-reviewed literature. 
 
Medicare rules say that molecular diagnostic laboratory tests such as the test at issue are subject to the MolDX 
application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate 
and unique test identifier. 
 
We looked at the file and Medicare rules. Per the DEX Diagnostics Exchange, this testing has been reviewed 
and found to not meet Medicare coverage criteria. Based on this information, we decided that Medicare rules 
for coverage of the ADmark testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ADmark Early Onset Alzheimer's genetic evaluation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit rendered on July 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the code was billed within seven days of telephone evaluation and management 
services. 
 
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 states that code 99215 (office visit) is not payable because it was billed 
within seven days of a telephone evaluation and management code and cites the American Medical Association 
coding guide as a source. The Plan has not provided any Medicare rules or documentation to support that the 
code is not payable as billed. Therefore, we decided that the Plan has to pay for the office visit rendered on July 
1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Glucocom blood glucose kit for the enrollee. 
 
You asked the Plan to pre-approve the kit. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are covered alternatives available. 
 
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 kit. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the requested diabetes supply is not covered. The covered alternatives available 
include: diabetes supplies made by Lifescan (e.g., One Touch Ultra). The enrollee is required to try all of the 
covered diabetes supplies before the plan can cover a diabetes supply that is not covered. The review has 
determined there is no medical necessity for this specific brand. 
 
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 kit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Glucocom blood glucose kit for the enrollee.