Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF admission and services. You say that SNF care is medically necessary 
so you can receive the therapy you need. The Plan denied your request. The Plan says you do not meet criteria 
for SNF care and the services you need can be provided at a lower level of care. 
 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 admission and services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 admission and services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel provided to 
the enrollee on February 4, 2022. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this testing is considered unproven and 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 the testing at issue in this case has not been cleared or approved by the Food and Drug Administration, 
and does not have sufficient high quality evidence available to support its use over current standard testing 
methods alone. There was no clinical information provided that suggests this patient was an exception in this situation. Therefore, the PCR testing will be considered not medically necessary at this time. 
 
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 a urine polymerase chain reaction (PCR) panel provided to the enrollee on February 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on August 
11, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the denial of air ambulance transport was appropriate given the clinical scenario. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
record indicates that the enrollee presented to the emergency department with concern of foreign body within 
urethra. The record provided does not document a clinical situation that required the need for immediate and 
rapid transportation that could not have been provided by ground ambulance. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on August 11, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy (PT) and occupational therapy (OT) services 
provided from November 9, 2021, to November 19, 2021. 
 
You asked the Plan to pay for the PT and OT services. You say that the provider is not out of network. You say 
that this claim should not have processed toward the Point of Service benefit. The Plan denied your request. 
The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT and OT services. Our reviewer says 
that the PT and OT services are medically necessary. Our physician reviewer found the provided 
documentation demonstrates that the enrollee had complex functional impairments and with trialing different 
assistive devices in which a professional therapist would be required for treatment. The reviewer also found 
that the occupational therapy is considered effective treatment for impairment of activities of daily living 
(ADL) and physical therapy is accepted as effective treatment for mobility impairments. Therefore, the 
reviewer found that the services are medically 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 PT and OT services have been met. Therefore, we decided that the Plan has 
to pay for the physical therapy (PT) and occupational therapy (OT) services provided from November 9, 2021, 
to November 19, 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 laboratory services (87150) provided on March 11, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (87150) provided on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care provided from June 7, 2021, to June 19, 
2021, as billed with the submitted Diagnosis Related Group (DRG) rate. 
 
You asked the Plan to pay for hospital care at the submitted DRG. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says the DRG submitted for this claim is not appropriate as the diagnosis of acute pulmonary insufficiency following thoracic surgery 
(J96.1) is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 hospital care at the submitted DRG. Our 
reviewer says that the diagnosis of acute pulmonary insufficiency following thoracic surgery (J96.1) is not 
supported in the medical record for this inpatient admission. Our physician reviewer found the documentation 
supports an admission for atherosclerotic heart disease of native coronary artery without unspecified angina 
pectoris, for which a coronary bypass and aortic valve replacement was performed on June 10, 2021. From the 
information that was received, the physician documentation noted acute pulmonary insufficiency following 
surgery in the progress notes; however, the documentation did not indicate that this condition was more than 
what would be an expected outcome in the post-operative period. Progress notes indicate that the enrollee was 
weaned to extubate on June 10, 2021, and as of June 11, 2021, was extubated and stable on 2L nasal cannula 
(NC). On June 15th, the enrollee was noted as stable on 4L NC. Additionally, provider documentation in the 
discharge summary notes that there were no complications. The review has determined that the medical records 
did not support the billing of acute pulmonary insufficiency following thoracic surgery (J96.1). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital care at the submitted DRG have not been met. Therefore, we decided 
that the Plan does not have to pay for the hospital care provided from June 7, 2021, to June 19, 2021, as billed 
with the submitted Diagnosis Related Group (DRG) rate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on November 19, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on November 19, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as in a skilled nursing facility, at home with home 
health services or in a long-term 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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 the Sprint PNS system (64555, 76942). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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 Sprint PNS system. Our reviewer 
says that the services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational of chronic neck pain. 
 
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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint PNS system (64555, 76942).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve K3 features for a lower limb prosthesis (L5981, L5986). 
 
You asked the Plan to pre-approve the K3 features for a lower limb prosthesis. You say that these features are 
medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 K3 features for a lower limb 
prosthesis. Our reviewer says that the requested prosthesis is medically necessary. Our physician reviewer 
found the documentation supports that patient is a K3 level ambulator. The requested features are medically 
appropriate for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the K3 features for a lower limb prosthesis have been met. Therefore, we 
decided that the Plan has to pre-approve K3 features for a lower limb prosthesis (L5981, L5986).  
 
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 next generation sequence testing provided to the enrollee on 
December 2, 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 testing that includes the FANCC gene is not covered.  
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found FoundationOneCDx (gene testing, including FANCC gene) was requested. FANCC gene testing is 
typically used to diagnose Fanconi anemia which is rare and characterized by typical clinical findings such as 
physical abnormalities and is diagnosed in children. There is insufficient support made in the notes provided 
that this patient has signs or symptoms, or age that fit this diagnosis to confirm with genetic testing with 
FANCC. As the ordered panel includes the FANCC gene, this request for FoundationOneCDx is not 
sufficiently supported and will be considered not medically necessary as requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for next generation sequence testing provided to the enrollee on December 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from October 
4, 2021, to November 18, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you should be covered for 
outpatient mental health services, so you do not know why these claims are not being paid. The Plan denied 
your request. The Plan says services you get from a provider who has opted out of Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services you received from October 4, 2021, to November 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on January 6, 
2022. 
 
You asked the Plan to pay for non-transport ambulance services. You say that you believe this service should 
be covered. The Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
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 January 6, 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 non-transport ambulance services you received on 
January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on September 15, 2021. 
 
You asked the Plan to pay for outpatient services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 outpatient services provided on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu for the enrollee. 
 
You asked the Plan to pre-approve Enhertu. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is a lack of an indication for using Enhertu in patients diagnosed with 
metastatic pancreatic cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our reviewer says that 
Enhertu is not medically reasonable and necessary. Enhertu is not FDA-approved for the enrollees diagnosis. 
The use of Enhertu is not supported by one of the major drug compendia or by clinical research that appears in 
a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of Enhertu. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia 10 mg tablet. 
 
You asked the Plan to pre-approve Kerendia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
 
 
 
 
 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 pre-approve Kerendia 10 mg tablet.