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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF 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. Our 
physician reviewer found while the patient has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the medication is 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aranesp. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Aranesp is medically reasonable or necessary for the enrollee. The 
documentation does not support that the Aranesp is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) testing provided on 
January 21, 2021. 
 
You asked the Plan to pay for the PCR testing. You say that the PCR testing provided on January 21, 2021, was 
medically necessary. The Plan denied your request. The Plan says the PCR testing provided on  
January 21, 2021, was 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 PCR testing. Our reviewer says that the 
PCR testing provided on January 21, 2021, was not medically necessary. Our physician reviewer found the 
review indicates that the enrollee is with fungal nails that underwent debridement of toenails and sent for 
infectious agent detection by nucleic acid testing. Confirmation of mycotic nail infections by laboratory testing 
is not medically reasonable and necessary when the clinical findings strongly support the diagnosis of 
onychomycosis, and treatment is not contraindicated. The clinical value and effectiveness of PCR testing in the 
setting of tinea unguium have not been demonstrated in the peer-reviewed literature. The review has 
determined that the provided PCR testing provided on January 21, 2021, was not medically reasonable or 
necessary for the enrollee in this case. 
 
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 PCR testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the polymerase chain reaction (PCR) testing provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pelvic positioning belt (K0108). 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Our reviewer found that the approved Group 3 power wheelchair already has a seat belt included therefore this 
request exceeds the enrollee's medical needs. Therefore, we decided that the Plan does not have to pre-approve 
a pelvic positioning belt (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that adding Ozempic to the enrollee's regimen will help 
him maintain adequate control of his blood sugars, help with weight loss, and he would benefit in whole. The 
Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit under this contract. The 
Plan says that the enrollee has Sanofi US which provides its own 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 Ozempic.  
 Benefits for Ozempic 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDX Prostate IntelliScore (EPI) genetic testing. 
 
You asked the Plan to pre-approve EPI genetic testing. You say that the requested genetic testing is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say that EPI genetic testing is covered for certain medical 
indications and when specific criteria have been met.  
 
We looked at the file and Medicare rules. The records show that the enrollee is 72 years old and has a PSA of 
2.15 ng/mL. Based on this information, we decided that Medicare rules for coverage of EPI genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve ExoDX Prostate 
IntelliScore (EPI) genetic testing.
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 LTACH services are not medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of the LTACH services. 
 
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 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 he is not currently 
receiving but that would be available at the LTACH facility.  
 
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 continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that continued inpatient psychiatric care 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for coverage of inpatient psychiatric care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 inpatient psychiatric care. Our reviewer 
says that inpatient psychiatric care is not medically necessary. Our physician reviewer found this enrollee did 
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the patients condition or for the purpose of diagnosis beyond the date in question. She was 
cooperative/compliant with treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the injections. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is evidence of right-sided facet mediated pain confirmed by provocative testing, 
absence of radiculopathy and the pain has been present for 3 months with documented failure to respond to 
noninvasive conservative care. The review has determined that the requested injections are 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 injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion procedure. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that the Vertiflex Superion is medically 
necessary. The Plan denied your request. The Plan says this service is experimental/investigational. 
 
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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex Superion procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided on July 28, 2021 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a resin-based composite. You say that you do not agree with the denial of this 
claim. The Plan denied your request. The Plan says the requested provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on April 9, 
2015. This means that the provider was opted out of Medicare for the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for a resin-based composite (D2391) provided on July 28, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the SureHands ceiling-
mounted patient lift purchased on June 10, 2021. 
 
 
 
 You asked the Plan to provide additional reimbursement for the SureHands patient lift. You say that this lift 
system was prescribed by your doctor, and you were told that this was a covered item by the Plan. You 
expected that the Plan would reimburse for the cost of this as your spouse is no longer able to provide your care 
without this assistance. The Plan denied your request. The Plan says it was found that criteria are met for a 
patient lift. However, review of the lift provided shows that code E0639 would adequately describe this device. 
The other codes would not be separately payable. The Medicare allowed purchase price for the lift described by 
E0639 is $1774.24 which was approved for reimbursement. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers patient lifts to allow an otherwise 
bed-confined enrollee to be transferred from bed to a chair, wheelchair, or bedside commode. E0639 describes 
a lift that is part of a ceiling-to-floor pole system. The rules also indicate that a Medicare-enrolled provider 
would be required to accept the Medicare allowed rate as payment in full. 
 
We looked at the file and Medicare rules. You were given codes to describe this lift system which included 
E0630, E0635, E0621, and E1399 (for a 10-foot suitcase ramp). However, review of the codes indicates that 
each code would describe a complete patient lift, and the invoice shows that a single patient lift was provided. 
It appears that E0639 does not completely describe the lift provided in this case, it does appear that the system 
installed exceeds the functionality of what Medicare covers. This lift system includes tracks to transport the 
enrollee from the bed to another room. Medicare coverage is limited to transferring from the bed to another site 
in the room, whether a chair, wheelchair, or commode. As the lift provided is ceiling-mounted, E0639 is the 
closest code, and it should be noted, is the highest paid code for patient lifts. As such, we find that this 
reimbursement amount is valid.  
 
If this system were provided by a Medicare Durable Medical Equipment (DME) supplier, the supplier would 
have been required to inform you of the Medicare cost and what would be beyond that coverage. It appears, 
however, that the company is not a Medicare DME supplier, which means they are able to charge you their 
own rate. Your Medicare plan is not obligated to reimburse you more than what Medicare would for a similar 
system. In addition, the ramp would be considered a home modification which cannot be covered by Medicare. 
Based on this information, we decided that Medicare rules for additional payment for the SureHands patient lift 
have not been met. Therefore, we decided that the Plan does not have to provide additional reimbursement for 
the SureHands ceiling-mounted patient lift purchased on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician visit to an assisted living facility (ALF) 
provided on October 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ALF visit. You say that these services were medically necessary, and 
the ALF should be responsible for obtaining needed authorization. The Plan denied your request. The Plan says 
this was a non-emergent visit for which no authorization was requested. Routine OON care is only covered 
when authorized by the Plan. 
 
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 the physician visit to an assisted living facility 
(ALF) provided on October 15, 2021, by an out-of-network (OON) provider.
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 daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support that it is 
medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a 
combination of these services) on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis, in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex foot system (L5980). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this exceeds the enrollee's needs. 
 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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the enrollee is a K3 ambulator. The health plan has authorized a 
K1 level prosthesis due to his mobility limitations.   
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex foot system (L5980).
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the 
LTACH services. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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.