Persius/hicric huggingface dataset:
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 exceeds criteria for an 
LTACH admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. 
 
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 all medically necessary care is being provided in the current acute care setting. 
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 Plan has approved ongoing care in the current acute care setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lung cancer screening with low dose computed 
tomography (LDCT) for the enrollee. 
 
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 must show that you have not had this scan within the last 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is 53 years 
old. This service is excluded for that age. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lung cancer screening with low dose computed tomography (LDCT) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension (L5848), an addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856), an addition 
to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension 
assist control (L5859) and an all lower extremity prostheses, flex foot system (L5980). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are necessary. The Plan denied 
your request. The Plan says the request for a microprocessor knee and foot does not meet Medicare criteria as 
reasonable and 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 pre-approve prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Medicare 
allows for replacement of a prosthesis or prosthetic component if there is a change in the physiological 
condition of the beneficiary, there is irreparable wear of the device or a part of the device or if the condition of 
the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the 
cost of a replacement device, or the part being replaced. In this case, the enrollee has been authorized for a 
replacement socket. The requested advanced foot and knee feature are not medically necessary as the 
documentation provided does not support that the enrollee is a K3 level ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension (L5848), an addition to lower extremity prosthesis, 
endoskeletal knee-shin system, microprocessor control feature (L5856), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control (L5859) 
and an all lower extremity prostheses, flex foot system (L5980).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 6, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the item rendered is not supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the progress notes submitted did not mention of ordering or utilizing 
this item for treatment. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral 
orthosis provided on April 6, 2022.
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 services are 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 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 clinical documentation shows that the enrollee is refusing skilled therapy sessions 
without any medical reason listed thus based on available documentation the enrollee would seem unwilling to 
participate in skilled therapy. The enrollee does have medical assessment needs and skilled nursing would be 
required but there is no reason documented as to why the enrollee would require daily skilled nursing thus from 
a practical standpoint the enrollee does not require daily services on an inpatient basis in a 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 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 pay for the laboratory services coded as 87801, 87798 and 87481 
provided on January 12, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that for review and reconsideration you are 
including a copy of the medical records that will show the medical necessity of the services rendered. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 laboratory services coded as 87801, 87798 and 
87481 provided on January 12, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on 
April 6, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgical services. You say that you were not advised 
of the copayment prior to the procedure being performed and have never had to pay a copayment for this 
procedure before. The Plan denied your request. The Plan says the copayment was billed correctly. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $200 for outpatient surgical services. 
 
 
 
 
 
 
 
 The enrollee has been asked to pay $200 for outpatient surgical services. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for outpatient surgical services provided on April 6, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on April 23, 2021, through May 22, 
2021. 
 
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the date of the pyhsician signature is 
illegible and cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not substantiated their denial. The documentation 
submitted does not clearly indicate that the physician signature was dated after the claim for the episode was 
submitted. It is the burden of the Health Plan to substantiate their denial with evidence. Therefore, we decided 
that the Plan has to pay for home health services provided on April 23, 2021, through May 22, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 19, 2022, to 
May 20, 2022. 
 
You asked the Plan to pay for the services provided. You say that you have a contract to be reimbursed at a per-
visit rate. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We looked at the file and the rules. We find that the claim was not billed as required. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from April 19, 
2022, to May 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a generator, neurostimulator (implantable), non-rechargeable with 
carotid sinus baroreceptor stimulation lead(s) (C1825) and an implantation or replacement of carotid sinus 
baroreflex activation device; total system (0266T). 
 
You asked the Plan to pre-approve an outpatient procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says that they cannot approve the service. The Plan also says they 
consider carotid sinus baroreflex activation device unproven and untried for treatment of congestive heart 
failure. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 outpatient procedure. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Barostim Neo may have a limited role in enrollees who have significant recurrent symptoms 
and signs of significant CHF despite full guideline directed therapy with randomized published data and 
specific FDA indications for its use which are met in this situation. The enrollee would therefore meet medical 
necessity and reasonableness criteria of the applicable CMS Section 1862(a) 1 (A) rule for the use of Barostim 
in this clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient procedure have been met. Therefore, we decided that the Plan has 
to pre-approve a generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor 
stimulation lead(s) (C1825) and an implantation or replacement of carotid sinus baroreflex activation device; 
total system (0266T).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on January 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that this is a Covid-19 claim. The Plan denied 
your request. The Plan says the facility must be enrolled 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 emergency room services provided 
on January 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT is covered when certain criteria are met. 
 
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 SBRT. Our reviewer says that the 
services are medically necessary.  Our physician reviewer found SBRT is within the accepted standards of care 
and it would meet the general medical necessity criteria by virtue of treatment furnished according to accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Body Radiation Therapy (SBRT).   
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health skilled nurse visits. 
 
You asked the Plan to pre-approve six (6) additional home health skilled nurse visits. You say that additional 
home health skilled nurse visits are medically necessary. The Plan denied your request. The Plan says 
additional home health skilled nurse visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 six (6) additional home health skilled 
nurse visits. Our reviewer says that additional home health skilled nurse visits are not medically necessary. Our 
physician reviewer found based on the documentation provided, the health Plans denial should be upheld. The 
enrollee does not have documented home health skilled nurse needs (i.e., intravenous, complex wound care, 
new ostomy). The enrollee appears to have available caregivers. As such, the requested ongoing home health 
skilled nurse services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six (6) additional home health skilled nurse visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve six (6) additional home health skilled nurse visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on March 1, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the medically necessary services at issue were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for OON 
care have not been met. 
 
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 nursing facility care (99309) provided on March 1, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads, for multiple nerve stimulation (E0730). 
 
You asked the Plan to pre-approve the TENS device. You say that you have tried physical therapy, acupuncture 
and chiropractic treatment, however nothing has helped your condition. Electrotherapy was suggested to 
manage pain symptoms until getting the injection. The Plan denied your request. The Plan says the requested 
service does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the TENS device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The NCD specifically excludes the use of TENS for low back pain unless the patient 
is enrolled in a clinical trial of TENS approved by CMS.  Therefore, the request is deemed not medically 
reasonable or 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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for 
multiple nerve stimulation (E0730).