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 does meet the LTACH 
admission criteria. You also say that you believe in order to sustain a safe and sustainable discharge, LTACH is 
the best option for the enrollee's care. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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. Our reviewer also found that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you have provided the supporting 
documentation for the services rendered and you would like the claim reprocessed. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 
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 nursing facility care provided on April 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service provided to the enrollee was 
medically necessary and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 nursing facility care provided on March 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has been instructed in a home exercise program. The 
enrollee's deficits do not require ongoing formal therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 19, 2022, to 
February 10, 2022. 
 
You asked the Plan to pay for home health services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the submitted physicians orders to support skilled nursing is not 
signed and dated by the physician 
 
The Plan must follow Medicare rules. Medicare rules say that that HHAs may not submit a claim until after all 
services are provided for the period and the physician has signed the plan of care and any subsequent verbal 
order. 
 
We looked at the file and Medicare rules. The file shows that the plan of care has not been signed by the 
physician. Based on this information, we decided that Medicare rules for coverage of home health services 
have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for home health services provided from January 19, 
2022, to February 10, 2022.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COPD exacerbation 
and myocardial infarction. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a FoundationOneCDx genetic test (0037U) provided on 
March 1, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the claim at 
issue was not submitted with a unique test identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 
  We looked at the file and Medicare rules. In this case, the claim for the service at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for a FoundationOneCDx 
genetic test (0037U) provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care to be provided after a Deep 
Brain Stimulation procedure. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that a one-day inpatient stay after a Deep 
Brain Stimulation procedure is medically necessary. The Plan denied your request. The Plan says the Deep 
Brain Stimulation procedure is approved while the inpatient stay is denied as this procedure is an ambulatory 
procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record does not show that the admitting physician reasonably expects that 
your necessary hospital care will span two midnights as the specific request was for a one day stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care to be provided after a Deep Brain Stimulation 
procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say the services were medically necessary. You say 
the place of service code was correct. The Plan denied your request. The Plan says they are unable to verify 
your license.  
The Plan must follow Medicare rules. Medicare rules say that laboratory providers must submit claims 
correctly. Independent laboratories must include the CLIA number on the Form CMS-1500 claim. 
 
The case file shows your claim form does not include the CLIA number confirming you hold a valid license. 
The case file also shows the Plan requested records from you, but no records were received. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 26, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) scan provided on May 30, 2021. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says that the CT scan was 
not medically necessary. 
 
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 pay for the CT scan. Our reviewer says that the 
requested CT scan is medically reasonable and necessary. Our physician reviewer found that the enrollee has a 
confirmed diagnosis of malignant left pleural effusion. The CT scan of the abdomen was appropriate as a way 
to look for subdiaphragmatic tumor. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pay for 
the computed tomography (CT) scan provided on May 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test (91065). 
 
You asked the Plan to pre-approve a hydrogen breath test. You say that you have had stomach issues for eight 
months now and have been going through all the steps to figure out the problem. It has been very stressful on 
your body and mind. You also say you would like this test approved so you can know exactly what is wrong 
with you before taking a specialty strong medication. The Plan denied your request. The Plan says Medicare 
does not cover breath tests to diagnose bacterial overgrowth. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a hydrogen breath test have not been met. Specifically, the requested test is not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a hydrogen breath test 
(91065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on May 
12, 2022. 
 
 
 You asked the Plan to pay for a determination of refractive state (92015). You say that this was not a refraction. 
You also say it was an evaluation for surgery. The Plan denied your request. The Plan says eye refractions are 
only covered by your plan if performed by a participating eye quest provider and performed as a routine 
screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when certain services are covered when performed by a Plan routine 
vision care provider. 
 
We looked at the file and the Plan's rules. The Plan states that eye refractions are covered during a routine 
exam. Based on this information, we decided that the Plan's rules for coverage of a determination of refractive 
state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a determination 
of refractive state (92015) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
December 7, 2021. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an ineligible 
provider.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Specifically, the record indicates that the services in 
this case were rendered by an acupuncturist who was not under the supervision of a physician, physician 
assistant, or a nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to 
pay for the acupuncture treatment (97810, 97811) provided on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right below the knee prosthesis with advanced foot-K3 
ambulator. 
 
You asked the Plan to pre-approve a right below the knee prosthesis with advanced foot-K3 ambulator. You 
say that the requested right below the knee prosthesis with advanced foot-K3 ambulator is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested right below 
the knee prosthesis with advanced foot-K3 ambulator. 
 
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 a right below the knee prosthesis with advanced foot-K3 ambulator. Our reviewer says that the enrollee does not meet criteria for the requested right 
below the knee prosthesis with advanced foot-K3 ambulator. Our physician reviewer found a right below the 
knee prosthesis with advanced foot exceeds the enrollee's functional need and is not medically necessary per 
the Local Coverage Determination (LCD) Lower Limb Prostheses L33787 and the Social Security Act, Section 
1862 (a)1(A) and the 42 CFR 411.15(k). Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The documentation from the physician does not support that this enrollee's 
functional level is a K3 level. 
 
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 right below the knee prosthesis with advanced foot-K3 ambulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a right below the knee prosthesis 
with advanced foot-K3 ambulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbosacral injections (64493). 
 
You asked the Plan to pre-approve the injections. You say that the provided records support the medical 
necessity of the requested lumbosacral injections. The Plan denied your request. The Plan says the requested 
services are not reasonable or 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 the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. The enrollee has tried physical therapy and Chiropractic 
service. On Physical exam, sacroiliac joint tenderness was noted as well as positive right straight leg raising. 
The enrollee has 2 other probable pain generators. 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbosacral injections (64493).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested group 3 power wheelchair and accessories. 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power 
wheelchair and accessories. Our physician reviewer found based on the documentation provided, the enrollee is 
not using a ventilator, does not use intermittent catheterization and is not at high risk for skin breakdown. The 
enrollee does not meet criteria for the requested group 3 power wheelchair and accessories per Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.