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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show complex rehabilitation needs. 
 
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 your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
pulmonary embolism. 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
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 is too medically complex and skilled 
nursing facility care is not acceptable per the enrollee's condition for a lower level of care. Close medical 
supervision is needed, and the enrollee has been on long term acute care for 2 months and was hospitalized 
prior to LTAC. The Plan denied your request. The Plan says the enrollee does not meet IRF criteria, is not 
medically necessary, and a lower level of care might be appropriate. It is feasible to meet the enrollee's needs at 
an alternate level of care, such as skilled nursing facility, or long term acute 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was admitted for respiratory failure, congestive heart failure, atrial fibrillation and 
hyponatremia. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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 been met. Therefore, we decided that the Plan does not have to 
pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 25, 2022. 
 
You asked the Plan to pay for the panel testing. You say that the testing was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel at issue includes the FANCC gene. Panels of tests 
that include this gene are statutorily excluded. 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 gene panel testing 
provided on January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says skilled criteria for this level of care has not been met. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD.  
Chronic CO2 retention is suspected, although not documented with an ABG done while stable as an outpatient.  
The enrollee may benefit from bipap with AVAPS during sleep. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting coverage for inpatient 
rehabilitation for the enrollee. The Plan denied your request. The Plan says that the enrollee's therapy needs are 
not intensive and do not require admission to an IRF to access the appropriate level of therapy. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was admitted to an acute hospital on July 31, 2022, after a fall due to right sided weakness 
and found to have a stroke. The enrollee initially had aphasia which cleared quickly. The enrollee continues 
with right sided weakness, dysarthria, and expressive aphasia. The enrollee had an acute episode of gout being 
treated. The enrollee is currently being evaluated for atrial fibrillation as a source of the cerebral vascular 
accident (CVA). The enrollee also has multiple areas of infarcts in the brain. On review of the available 
records, the enrollee with a CVA as described, meets the criteria for IRF admission. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from December 11, 2021, to 
January 12, 2022. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says if you receive the 
covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance 
percentage multiplied by the Medicare payment rate for participating providers. (Remember, the plan covers 
services from out-of-network providers only in certain situations, such as when you get a referral.) 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
 We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Based on this 
information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided from December 11, 2021, to 
January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 23, 2022, and  
April 29, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 
physicians services. 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 physician's services provided on April 23, 2022, 
and 
April 29, 2022.
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 enrollee is medically stable and will 
benefit to transfer to LTACH due to current medical management necessity and prolonged hospitalization. The 
Plan denied your request. The Plan says the LTACH admission is not medically necessary. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care setting where they are currently 
receiving 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. Daily skilled services are not shown to be required 
to establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist (99204) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with an oncologist. You say that there has been a delay in 
your care due to unavailability of an oncologist which forced you to find an OON provider. You are requesting 
reconsideration to see the requested provider. The Plan denied your request. The Plan says 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 with an oncologist (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care. 
 
You asked the Plan to pre-approve chiropractic care. You say that chiropractic care is medically necessary. The 
Plan denied your request. The Plan says chiropractic care is not medically necessary and there is no 
documentation of bony abnormalities and no indication of subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic care. Our reviewer says 
that the record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. Our physician reviewer found that the record indicates the enrollee has low back 
pain from degenerative disc disease but does not indicate the presence of vertebral subluxation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve chiropractic care.
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 a retired registered nurse and an emergency 
room trauma nurse and you feel the best chance of recovery is the acute care. The Plan denied your request. 
The Plan says you do not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 were admitted for respiratory failure. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 below the knee prosthetics (L5981, L8420x2, L5620, 
L5673, L5668, L8400, L5968, L5655, L5671, L5629x2, L8470, L5020, L5301, L5637, L5940, L5645, L5910, 
L5704, L5785) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve below the knee prosthetics. You say that the in-network provider is too far 
from the enrollee's home. The enrollee was unhappy with the products he received from the provider 
previously. The enrollee is currently holding his prosthetics together with duct tape. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. There are in-
network providers available. 
 
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 
below the knee prosthetics (L5981, L8420x2, L5620, L5673, L5668, L8400, L5968, L5655, L5671, L5629x2, 
L8470, L5020, L5301, L5637, L5940, L5645, L5910, L5704, L5785) to be provided by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show diabetes or kidney disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tab 15mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Xarelto tab 15mg for the 
enrollee.