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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has no stamina with Parkinsons disease 
and needs rehab to get better. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you did not want to go to the hospital 
because you were not hurt.  You say that you expected to have to pay something but not the entire charge. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) 
provider. 
 You asked the Plan to pre-approve a second opinion with an OON provider. You say that you have a very rare 
form of cancer and need to have an Oncologist that is specialized in this form of cancer. You say that your 
cancer is spreading, and the network Oncologists are not specialized in this form of cancer. You say that the 
requested provider has treatments available that are not available to the Oncologists in Florida. The Plan denied 
your request. The Plan says they have network Oncologists and tertiary care providers available that can 
provide the services at issue. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 second opinion with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found no clear rationale was given for why you need a second opinion. The Plan's network offered the 
standard of care with Cisplatin/Gemcitabine. There is nothing unique about your condition that would make it 
medically necessary for you to see the requested OON provider. The Plan has shown that they have network 
providers who meet the standards of care required for treatment of the enrollee's 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 a second opinion with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot put more than twenty-five 
pounds on their operated right leg, and they are a fall risk for further injury. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and the enrollee can safely receive the care they need in 
another setting. 
 
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 close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
would benefit from physical and occupational therapy, they can get their rehab needs in a lower setting such as 
a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 a skilled nursing facility cannot provide 
adequate care. The Plan denied your request. The Plan says the enrollee's needs are being med in the current 
acute setting. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with chronic sacral and buttocks 
decubitus ulcers with underlying osteomyelitis in the setting of T-12 paraplegia. The record indicates that the 
enrollee has ongoing medical issues and still requires acute care services.  The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied. Therefore, 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have continued back and neck pain with 
weakness in your legs. You say that you have trouble swallowing and feel that an IRF is the care you need. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can be 
provided safely in other settings. 
 
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 you are medically stable and do not need close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical therapy and occupational therapy, you can get the care you need at a lower setting such as a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on April 28, 2022. 
 
You asked the Plan to pay for a domiciliary, rest home visit. You say that the services were provided to the 
member in an Assisted Living Facility (ALF) and the ALF is responsible for obtaining prior authorization for 
all their patients, which should also cover the medical treatments provided by this doctor as it was rendered in 
good faith. The Plan denied your request. The Plan says an authorization was not obtained prior to the services 
being rendered and the provider is not participating with the member's Plan. The services were not urgent or 
emergent. It was also determined the services rendered could have been provided by a participating provider 
under the members Plan. 
 
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 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 a domiciliary, rest home visit provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 2 Sensors. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 Freestyle Libre 2 Sensors. Our reviewer 
says that the requested sensors are not medically reasonable and necessary. Our physician reviewer found that 
the enrollee does not take insulin, so he does not meet criteria for CGM 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 Freestyle Libre 2 Sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Libre 2 Sensors.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for March 28, 2022. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says the billed 
code is not supported. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 procedure code 99285. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that for emergency department 
services, 3 of 3 key components must be met or exceeded, for each level of service.  In this case, the records 
support a comprehensive history, a comprehensive exam, and medical decision making of moderate 
complexity, which supports code 99284, and not 99285. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for March 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency ambulance transportation (A0428), 
ground mileage (A0425), and ambulance oxygen and oxygen supplies (A0422) provided on January 6, 2022. 
 
You asked the Plan to pre-approve the non-emergency ambulance transportation, ground mileage, and 
ambulance oxygen and oxygen supplies. You say that you are requesting a retrospective prior authorization. 
The Plan denied your request. The Plan says prior authorization is required for non-emergent ambulance 
transportation. 
 
Medicare pays for non-emergent ambulance services only when they are medically reasonable and necessary, 
and when prior authorization has been obtained. The Plan follows the same rules.  
 
 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 non-emergency ambulance transportation, ground mileage, and ambulance 
oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve the non-emergency ambulance transportation (A0428), ground mileage (A0425), and ambulance 
oxygen and oxygen supplies (A0422) provided on January 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 6, 2022, to April 4, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim was billed with an unacceptable principal diagnosis. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was billed with principal diagnosis J12.82 (pneumonia due to coronavirus disease 2019). This means the claim 
was billed with an unacceptable principal diagnosis. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from March 6, 2022, to April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on April 8, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR testing is not medically reasonable and necessary in this case. Urine PCR amplification 
techniques raise considerable concerns regarding contamination from one specimen to another, creating the 
potential for false-positive results. The clinical interpretation of PCR results may also be challenging. 
Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead 
microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and 
positive and negative predictive values of PCR have not been reported in large groups of patients for many of 
the microorganisms. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2022, billed with 
codes 81227, 81230, 81231, 81232, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 3, 2022, billed with codes 81227, 81230, 81231, 81232, 0031U, 0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 10, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary, and you are 
appealing with supporting records. The Plan denied your request. The Plan says the enrollee must receive care 
from a network provider. 
 
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 nursing facility visit provided on June 10, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic failure with 
hypoxia secondary to COPD/Emphysema. She also has chronic lung infection. The Plan denied your request. 
The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with Auto-EPAP (AE) 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has very severe COPD 
and pulmonary infection with MAI. ABGs during a recent hospitalization for a COPD exacerbation were 
consistent with acute on chronic hypercarbic respiratory failure. The enrollee improved on BiPAP. She may 
benefit from BiPAP with AVAPS during sleep. This has not been tried. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).