Persius/hicric huggingface dataset:
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. You say that the services at issue are coverable under Medicare 
The Plan denied your request. The Plan says daily skilled services or a therapist is not needed. 
 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 from a nursing perspective, the enrollee received oral and inhaled medications. The 
enrollee received intravenous antibiotics at dialysis. The enrollee had stable vital signs and used oxygen via 
nasal cannula. Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy. 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous test (95004) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the diagnostic service. You say that you have never seen the in-network 
provider. You say that any time you have had an appointment with the in-network provider, you have only seen 
a nurse. You also say that you are very ill and have pneumonia. The Plan denied your request. The Plan says 
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 confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve a percutaneous test (95004) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvigil. 
 
You asked the Plan to pre-approve Nuvigil. You say that the requested drug is medically necessary The Plan 
denied your request. The Plan says the requested drug is self-administered and does not fall under Part B 
coverage. The Plan says that they do not administer the enrollee's pharmacy benefits. 
 
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 Nuvigil.  
 
Benefits for Nuvigil may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH 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. Our 
physician reviewer found that the record indicates that the enrollee continues to have acute medical issues and 
still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested Group 3 power wheelchair with a single 
power option (power tilt seating system). 
 
You asked the Plan to pre-approve the requested type of PWC. You say that it is felt that the specific PWC 
requested is medically necessary and should be approved. The Plan denied your request. The Plan says the 
records do not show the need for a power tilt seating system, thereby disallowing coverage for the requested 
PWC base code. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with single power option may only 
be covered when the enrollee meets criteria for a power tilt or power recline seating system. 
 
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 requested type of PWC. Our reviewer says that the criteria for the requested Group 3 PWC with a single power option are not met in this 
case. Our physician reviewer found the enrollee is a 78-year-old patient with a diagnosis of hemiplegia due to a 
stroke. Provided records do not support that the enrollee is high risk for skin breakdown, has a history of 
pressure ulcer(s) or has had skin flap surgery. Records do not document she performs bladder self-
catheterization or that she has increased muscle tone or spasticity. Thus, the power tilt option and the single 
power option PWC base do not meet LCD criteria for coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested type of PWC have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the requested Group 3 power wheelchair with a single power option (power 
tilt seating system).
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 with aggressive treatment the enrollee will receive 
treatment that should allow him to return to a good functioning level. The Plan denied your request. The Plan 
says the enrollee does not meet medical necessity criteria for admission. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for influenza, pneumonia, and myocardial infarction. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided a in a different level of care. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polymerase chain reaction (PCR) lab testing services 
provided on March 28, 2022. 
 
You asked the Plan to pay for PCR lab testing services. You say that you would like this claim reprocessed and 
approved for payment based on medical necessity. The Plan denied your request. The Plan says this is an 
experimental / non-covered service. 
 
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 PCR lab testing services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a female with diagnosed Tinea unguium and related nail dystrophy. 
She was recommended Epsom soaks. A PCR test was performed on March 28, 2022, of the nail to identify 
species of infection. However, there was no justification for using this testing over culture which is standard of 
care and would not take long or lead to any negative results for this patient where the infection is very slow to 
affect the nail. Most of the time, if tinea is suspected, treatment with a topical antifungal agent is recommended as determining the specific species does not typically lead to any different treatment plan. There was no 
justification found in the provided statements and records suggesting this case was unique in any way to justify 
PCR testing or how it would lead to an improved outcome over standard of care methods. Therefore, this 
request for PCR testing will be considered 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 PCR lab testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for polymerase chain reaction (PCR) lab testing services provided on March 28, 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 this admission is medically necessary. 
The Plan denied your request. The Plan says there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker, also known as a crutch substitute. 
 
You asked the Plan to pre-approve the requested knee walker. You say that you need this knee scooter because 
you are scheduled for foot surgery which will result in a heavy bandage and splint. You state that you will be 
unable to put any weight on the foot, so this device is necessary. You state that you do not feel safe using 
crutches. The Plan denied your request. The Plan says this is not a covered item, as it has not been found to be 
safe and effective for the Medicare population. 
 
The Plan must follow Medicare rules. Medicare rules say that the DME contractor responsible for coverage of 
medical equipment has found that the evidence is not sufficient to determine that a knee walker is medically 
reasonable and necessary. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested knee walker have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a knee walker, also known as a crutch substitute.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care service provided on July 3, 
2022. 
 
You asked the Plan to waive the copayment for emergency care service. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency care service. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care service 
provided on July 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is completely dependent on others and 
will not receive the adequate care needed at a skilled nursing facility. The Plan denied your request. The Plan 
says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting 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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services 
with regular physician evaluation. The enrollee's care needs can be met 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $60 copayment for ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ultrasound provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 36478 provided to the 
enrollee on August 2, 2022. 
 
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 there is no additional documentation or confirmation that indicates or supports an additional 
ablation which was billed and remains denied. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code  is "Endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support more than one unit of CPT 36478. The MUE is only 1, and the procedure code is for the first vein 
treated. There is a more appropriate procedure code that can be billed for the additional vein being treated. 
 
We looked at this coder'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 an additional unit of procedure code 36478 provided to the enrollee on August 2, 2022.
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. You say that the services at issue are coverable under Medicare 
The Plan denied your request. The Plan says the daily skilled nursing or a therapist is not needed. 
 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 from a nursing perspective, the enrollee received oral and inhaled medications. The 
enrollee had stable vital signs and used oxygen via nasal cannula. Regarding rehabilitation services, the 
enrollee received physical therapy and occupational therapy. The enrollee was non-ambulatory at baseline and 
required assist with activities of daily living skills. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is medcally necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Infed and Venofer. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).