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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87798, 87653, 87640, 87481) provided January 24, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. The PCR 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 urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the urine PCR panel testing (87798, 87653, 87640, 87481) provided January 24, 
2022, was 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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing (87798, 87653, 87640, 
87481) provided January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 10, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he/she will be required to see. You also say that once the provider arrives at the 
facility, he/she receives a list of patients who require treatment and provides services to all of them, since there 
is currently no in-network doctor who can treat the patients in this facility. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan. The Plan also says that authorization was not obtained 
prior to the services being rendered. 
 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 domiciliary or rest home visit provided on June 
10, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is of long-term 
duration, and they have failed non-operative treatment. You say that the Intracept procedure is the only solution 
and should be approved. The Plan denied your request. The Plan says there are not enough studies on Intracept 
to show it is safe and effective. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, and more research is needed to show safety 
and efficacy. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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. 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 were admitted for cervical spine surgery. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
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 an ILR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric bed. 
 
You asked the Plan to pre-approve a total electric bed. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric bed have not been met. Therefore, we decided that the Plan does not have to pre-
approve a total electric bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cyclophosphamide. 
 
You asked the Plan to pre-approve cyclophosphamide. The Plan denied your request. The Plan says current 
guidelines do not support the use of this drug for the diagnosis provided. 
 
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 cyclophosphamide. Our reviewer says 
that the requested use of cyclophosphamide is not FDA approved for the enrollees diagnosis. Our physician 
reviewer found that the use of cyclophosphamide is not approved in combination with bevacizumab. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cyclophosphamide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cyclophosphamide.
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 enrollee's rehabilitation needs warrant an IRF 
level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in 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 pay for the medication assisted treatment provided on January 31, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the claim was not billed with the correct type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code G2067 was not billed with a type of bill suitable for payment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the medication assisted treatment provided on January 31, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your 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. 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 were admitted for coronary artery bypass grafting and mitral valve replacement. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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 pay for subsequent nursing facility care provided on April 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that authorization was not obtained 
prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. 
The Plan denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 subsequent nursing facility care provided on April 
4, 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. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) 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 a home ventilator is not medically reasonable and necessary. The record indicates that you have chronic 
respiratory failure from chronic obstructive pulmonary disease. The record indicates that you were successfully 
treated with BiPAP. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. Our physician reviewer found that your condition does not meet Medicare criteria for 
a home ventilator. 
 
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.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for Part B drugs. We decided that the Plan does not 
have to waive the copayment for a specialist visit and an x-ray.   
You asked the Plan to waive the copayment for a specialist visit, Part B drugs, and an x-ray. You say that you 
should not have to pay an amount that is this high. The Plan says that the cost applied was correct. 
 
We decided that the Plan has to waive the copayment for Part B drugs.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 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 did not make reasonable and diligent efforts to forward information to us. The Plan did not submit an 
Explanation of Benefits (EOB) or other payment document showing the allowed amount of the Medicare Part 
B prescription drugs. Without this information, we cannot determine whether the coinsurance amount that you 
have been asked to pay is mathematically correct based on your Plans benefits. Therefore, the Plan has not 
shown that the coinsurance amount you have been asked to pay is correct or justified according to Medicare 
rules and your contract with the Plan. Therefore, we decided that the Plan has to waive the copayment for Part 
B drugs.  
 
We also decided that the Plan does not have to waive the copayment for a specialist visit and an x-ray. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for a specialist visit and a $45 copayment for an x-ray ($50 + $45 = $95). Therefore, we decided 
that the Plan does not have to waive the copayment for a specialist visit and an x-ray. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are supposed to go to rehabilitation. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - 
the intensive rehabilitation therapy program provided in 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.