Persius/hicric huggingface dataset:
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 at high risk for a poor 
outcome including death if discharged to a lower level of care. You say that the enrollee requires an LTACH 
level of care and is stable and suitable for discharge. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can get the services they need in another setting. 
 
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 improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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 LTACH services.
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 you are requesting reconsideration for 
the denial of an LTACH admission. You say the LTACH is the most appropriate setting for the enrollee to 
continue their treatment and give them the best opportunity to return to their baseline. 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 Plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hizentra. 
 
You asked the Plan to pre-approve Hizentra. You say that coverage for intravenous immunoglobulin 
administered in the home is a benefit covered under Medicare Part D based on this enrollee's diagnosis. The 
Plan denied your request. The Plan says the dispensing plan meets for Part D coverage: the pharmacy dispenses 
the drug to the enrollee; or is pharmacy shipped to the provider (on behalf of the enrollee); or is given in the 
enrollee's home or in assisted living- without an infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Hizentra.  
 
  Benefits for Hizentra 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for Part B coverage. The Plan also says the enrollee is not receiving chemotherapy. 
 
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 Ondansetron.  
 
  Benefits for Ondansetron 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on September 12, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on September 12, 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 will benefit from aggressive 
rehabilitation. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee can receive the care they need in another setting. 
 
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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit for physical and occupational therapy the enrollee's needs can be provided in an alternate setting such as 
skilled nursing 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre kit sensor. The Plan denied your request. The Plan says a 
continuous glucose monitor is not covered under Medicare if you are not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre kit sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre kit sensor.
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 will benefit from an acute rehab to 
optimize their level of functioning prior to returning home. You say that the enrollee has a serious life-
threatening medical problem that requires interdisciplinary therapy care. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and the enrollee can receive the care they need in 
another setting. 
 
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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit for physical and occupational therapy the enrollee's needs can be provided in an alternate setting such as 
skilled nursing 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the records support that a bilevel positive 
airway pressure (BiPAP) has been tried and failed, it is not keeping carbon dioxide (CO2) levels down. You 
also say without the non-invasive ventilator, the enrollee is at great risk for a worsening condition. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) that could be delivered 
by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the enrollee has a diagnosis of COPD and was recently hospitalized with an exacerbation of heart failure. 
Arterial blood gas (ABG) was consistent with chronic hypercarbic respiratory failure. The enrollee was placed 
on BiPAP, but the partial pressure of carbon dioxide (PaCO2) remained elevated 24 hours later. Our reviewer 
found that it is not clear from the record how much the BiPAP was used. There are no pulmonary function tests 
to assess the severity of the COPD. There is no ABG done while stable to confirm chronic CO2 retention. Our 
physician reviewer found if this enrollee does have severe COPD with chronic CO2 retention, they may benefit 
from BiPAP with AVAPS during sleep as an outpatient. This has not been tried and demonstrated to fail as an 
outpatient. Our reviewer also found that Medicare does not cover a home ventilator when used at settings that 
can be provided with 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 15, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. 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 a $20 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on July 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker (33274). 
 
You asked the Plan to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker. 
You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for coverage. 
 
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 transcatheter insertion or replacement 
of permanent leadless pacemaker. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the evidence provided would 
not meet criteria for pacemaker implant. There is insufficient documentation to support the medical necessity 
for the requested cardiac pacemaker in this enrollees clinical management. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter insertion or replacement of permanent leadless pacemaker have 
not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion or 
replacement of permanent leadless pacemaker (33274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82306, 82607, and 82746 provided on 
February 11, 2022. 
 
You asked the Plan to pay for procedure codes 82306, 82607, and 82746. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, procedure codes 82306, 82607, and 82746, were requested solely for screening 
purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for procedure codes 82306, 82607, and 82746 provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 20, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Signatera test (81479). 
 
You asked the Plan to pre-approve the Signatera test. You say that the enrollee needs this testing. The Plan 
denied your request. The Plan says the records do not show that the enrollee has a type of cancer for which the 
Signatera test is indicated. Additionally, there is no documentation that the enrollee is receiving treatment with 
an immune check point inhibitor. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage of the Signatera test, the enrollee must 
have the diagnosis of disease progression, recurrence, or relapse for colon cancer and bladder cancer and 
monitoring of response to immune-checkpoint inhibitor therapy for any solid tumor. 
 
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 Signatera test. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that per the National Comprehensive 
Cancer Network (NCCN) Guidelines Version 1.2023 Head and Neck cancers, circulating tumor cells such as 
Signatera are not considered a standard of care for surveillance. Use is not supported by the medical literature. 
The service is not reasonable or 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 Signatera test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Signatera test (81479).
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 you have tried all the local facilities for physical 
therapy as well as a skilled nursing facility, but no one would take you because of the pain medication you are 
on. You say that you can do 3 hours of physical therapy. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and you can get the services you need in other settings. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837), provided on March 28, 2022, 
through October 20, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says Licensed Professional Counselors are not eligible for enrollment in the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837), provided on 
March 28, 2022, through October 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
October 18, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you were informed 
there would be no copayment for the PT visits. 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 a $40 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. This item/service falls within the 
outpatient rehabilitation service 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. The total you owe is $320 ($40 per visit x 8 visits = $320). Therefore, we 
decided that the Plan does not have to waive the copayment for each physical therapy visit provided on October 
18, 2022, to November 21, 2022.