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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee doesnt need complex therapy or have medical needs that 
require inpatient hospital interdisciplinary team. 
 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 IRF admission and services.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178). We decided that the 
Plan does not have to pre-approve a CT scan of the chest (71270).  
 
You asked the Plan to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74178) and 
CT scan of the chest (71270). You say that the enrollee had a CT of the chest done and needs further 
examination for abnormal findings. The Plan says that the records do not show that results of a thorough 
workup failed to reveal the cause of the enrollee's weight loss. 
 
  We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178).  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis 
(74178). Our reviewer says that a CT scan of the abdomen and pelvis is medically reasonable and necessary for 
the enrollee. Our physician reviewer found a CT scan of the abdomen and pelvis is reasonable in light of the 
weight loss over the past year. 
 
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 CT scan of the abdomen and pelvis (74178) have been met. Therefore, we 
decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178).  
 
We also decided that the Plan does not have to pre-approve a CT scan of the chest (71270). 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the chest (71270). Our reviewer 
says that a CT of the chest is not reasonable and necessary. Our physician reviewer found the enrollee had a CT 
of the chest with contrast on October 4, 2022, which revealed no findings of concern. 
 
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 CT of the chest (71270) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CT scan of the chest (71270). 
 
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 pre-approve ADTKD-UMOD gene known familial variant gene 
testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reported personal history of disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have no reported personal history of disease associated with this testing (including no gout or 
chronic kidney disease). The documentation does not indicate that you need this testing. 
 
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 pre-approve ADTKD-UMOD gene known familial variant gene testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the denial is unwarranted and inconsistent with 
currently accepted medical practice. The Plan denied your request. The Plan says the records do not document 
recent evaluation by a spine surgeon. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the minuteman procedure is experimental. 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77523x28, 
77525x28, 77014x28, G6002x28). 
 
You asked the Plan to pre-approve PBRT. You say that the requested PBRT is medically necessary taking into 
account all information outlined in this letter and all included medical records. The Plan denied your request. 
The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. There is no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer 
proton beam therapy on clinical trials, and to not routinely offer it to patients. Medicare criteria is not 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) (77523x28, 77525x28, 77014x28, G6002x28).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and stabilized in the acute care setting. You also say that the enrollee is stable to transfer to the LTACH for the 
continuation of care The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval. 
 
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 that the enrollee is stable and should only require short-term additional acute care 
services that can safely be administered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97110) billed for date of service 
April 10, 2021. 
 
You asked the Plan to pay for therapeutic procedures. You say that these services were medically necessary 
and were billed correctly. The Plan denied your request. The Plan says these services are not supported as 
billed. 
 
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 this service is not supported in the medical record. Specifically, the documentation shows that this 
claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical Therapy 
Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of therapeutic procedures have not been met. Therefore, we decided 
that the Plan does not have to pay for therapeutic procedures (97110) billed for date of service April 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites). The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current 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 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that based on the medical needs, attending 
physicians have determined that the enrollee is stable and suitable for transfer to LTAC. The Plan denied your 
request. The Plan says based on Medicare guidelines the long term acute care hospital services you are 
requesting do not meet the requirements for approval. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment in a LTACH. The enrollee has improved medically but continues to require care in an acute hospital. 
The enrollee can receive further care at the current acute care hospital or a lower level of care when deemed 
appropriate. 
 
 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 the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service, advanced life support, 
emergency transport services provided on January 2, 2022. 
 
You asked the Plan to waive the copayment for ambulance service, advanced life support, emergency transport.  
The Plan denied your request. The Plan says the claim history shows one claim (20220128841059200063) on 
file billed for observation services only. Per the EOC, observation is still considered to be outpatient services 
not inpatient. 
 
The Plan contract covers ambulance services. The Plan contract says there is a $175 copay for Medicare- 
covered ground ambulance benefits. Waived if admitted.  
 
We looked at the file and the Plans rules. The file shows that you were not admitted inpatient. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance service, advanced life support, 
emergency transport services provided on January 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and will require 
extended acute care. The Plan denied your request. The Plan says the LTACH services you are requesting do 
not meet the requirements for approval. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says skilled nursing 
facility level of care is not medically necessary for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found it is unclear if the enrollee is willing and able to partake in daily skilled therapy. The 
enrollee is functioning with minimal assistance. The enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found that the enrollee does 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97814, 99203, 97813) provided on 
February 25, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that this should be covered. The Plan denied your 
request. The Plan says you do not have a covered condition for these services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows that the acupuncture services at 
issue were provided to treat anxiety and insomnia. Acupuncture is not covered for these conditions under 
Medicare or the Plans acupuncture benefit. Therefore, we decided that the Plan does not have to pay for 
acupuncture services (97814, 99203, 97813) provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) and diagnostic services (36224, 
36226, 36227) with a neurologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and diagnostic services. You say that you are very emotional, 
concerned and sensitive about your provider 
being changed which has been causing panic attacks. The Plan denied your request. The Plan says although you 
have seen a specialist at a university center with specialized expertise in neurovascular procedures, the medical 
group has an equivalent specialist. You must use network providers to get your medical care and services. 
 
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 
an office visit (99214) and diagnostic services (36224, 36226, 36227) with a neurologist 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the complex needs of the enrollee would 
be best managed in an LTACH level of care. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be administered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is 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 LTACH services.