Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit and the laboratory services 
rendered by the out-of-network (OON) provider on May 25, 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 out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the hospital outpatient clinic visit and the laboratory services rendered by the out-
of-network (OON) provider on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without the use of a contrast dye (72141) MRI thoracic spine without contrast (72146) and MRI of the lumbar 
spine without contrast (72148). 
 
You asked the Plan to pre-approve MRI. You say that the medical records provided support the necessity of the 
services in dispute. The Plan denied your request. The Plan says the records provided do not support that the 
enrollee meets the criteria of the requested MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found There was insufficient support made for the MRIs of the spine as the patient did not report 
significant worsening of symptoms as they were chronic, and PE did not reveal any significant changes or signs 
of a red flag diagnosis to justify repeat imaging. Therefore, the MRIs will be considered not medically 
necessary based on the provided documentation. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the cervical spine without the use of a contrast dye (72141) 
MRI thoracic spine without contrast (72146) and MRI of the lumbar spine without contrast (72148).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for an OTC test kit for COVID-19 provided on 
January 18, 2022. 
 
You asked the Plan to reimburse you for an OTC test for COVID-19. You say that the online information, as 
well as acknowledgement by a pharmacist, confirmed that the Plan would reimburse you for an OTC 
COVID-19 test kit, which was purchased on January 19, 2022. The Plan denied your request. The Plan says 
that OTC COVID-19 test kits are not a covered benefit.  
 
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 provided the exact rule to support the denial. 
Additionally, the Plans portal says OTC tests for COVID-19 are not covered if purchased before  
January 15, 2022. The date of purchase is after January 15, 2022. Therefore, we decided that the Plan has to 
reimburse you for an OTC test kit for COVID-19 provided on January 18, 2022.  
 
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: 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 not being admitted into an IRF will seriously 
jeopardize your life, health, and ability to regain maximum function. The Plan denied your request. The Plan 
says you can safely receive the services you need in another setting such as a skilled nursing facility, at home 
with home health or with outpatient therapy. 
 
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 while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program that an IRF would provide. 
 
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 Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered for specific indications only. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has urinary incontinence. 
The records do not support that she is intolerant to or has failed anticholinergic therapy. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The criteria for coverage are not met and the Botox 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 3, 2021, to November 24, 2021. 
 
You asked the Plan to pay for home health services. You say that the claim was unjustly denied for timeliness. 
The Plan denied your request. The Plan says the RAP claim was not submitted within 5 days of the start of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 3, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from November 3, 2021, to 
November 24, 2021.
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 you do not have documented skilled nursing 
needs. Your wound care is not complex, and your wraps are not being changed daily. Your tube feeds are 
supplemental not primary. You do not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve physician's services to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. The Plan 
denied your request. The Plan says the Plans policy states tertiary care services are only allowed when certain 
criteria (rules) are met. For this level of care, the member must require one or more of the following: 1. 
Treatment that is not available at a lower level of care. 2. Treatment that is too unsafe to perform at a lower 
level of care. 3. Multiple specialty services as part of a complex coordinated plan of care.     
 
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 physician's services to be provided by 
the requested provider. Our reviewer says that the requested physician's services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that you were offered a primary  
in-network Urology physician that offers the same care, but you refused. There is no documented exceptional 
circumstances that would suggest better care and outcome would likely be achieved by seeing the tertiary care 
provider. Therefore, it will be considered 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 physician's services to be provided by the requested provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the 
requested provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic renal cell 
clear carcinoma. The Medicare approved cancer drug compendia do contain a supportive citation as noted 
above for the use of the requested drug in the enrollee's clinical situation. Opdivo 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve transportation to and from a provider's office outside of the plan 
area. 
 
You asked the Plan to pre-approve transportation services. You say that you were approved to see a 
rheumatologist outside of the plan's coverage area due to a lack of rheumatologists in the area. You also say 
that you require transportation to and from this appointment. The Plan denied your request. The Plan says that 
non-emergency transportation is available to medical appointments with contracted providers within the plan's 
service area. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers transportation services when non-emergency transportation is available to medical 
appointments with contracted providers within the plan's service area.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of transportation services have been met. Specifically, the file shows that 
there are no rheumatologists within the plans service area. Therefore, we decided that the Plan has to pre-
approve transportation to and from a provider's office outside of the plan area.  
 
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: 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 admission is medically necessary. The Plan 
denied your request. The Plan says IRF is not medically necessary and therapy can be provided at an alternative 
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. Our 
physician reviewer found that there is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 8, 2021, to September 16, 2021. 
 You asked the Plan to pay for the services. You say that the Medicaid State agency (CMA) may file a request 
for an appeal with respect to a claim for items or services furnished to a dually eligible beneficiary only for 
services for which the Medicaid State Agency has made payment, or for which it may be liable. The Plan 
denied your request. The Plan says there was no daily skilled nursing or therapist need. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 8, 2021, to 
September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve a transurethral waterjet ablation of the prostate. You say that the requested 
service is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
the requested service have not been met. 
 
The Plan must follow Medicare rules. The rules say that a transurethral waterjet ablation of the prostate is 
considered reasonable and necessary when the criteria listed in the Medicare rules section 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 a transurethral waterjet ablation of the 
prostate. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the records indicate that you have not demonstrated failure, 
contraindication, or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH. The 
records indicate fair efficacy with Tamsulosin and Finasteride. 
 
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 transurethral waterjet ablation of the prostate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a transurethral waterjet ablation of the prostate (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-
network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on July 29, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services do not meet the coverage requirements. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on their medical history and documentation, the enrollee is already at high risk and learning of 
their genetic risks would not have reasonably changed the optimal treatment plan for this patient. Therefore, 
this request for cardiac risk assessment genetic screening testing will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on July 29, 2021.