Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 prosthesis replacement. 
 
You asked the Plan to pre-approve the replacement. You say that this is medically necessary. The Plan denied 
your request. The Plan says the notes do not show why the current K3 foot, which is less than three years old, 
and therefore under warranty, needs to be replaced. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Replacing an item that is less than three years old is not reasonable and necessary in this case. Based on this 
information, we decided that Medicare rules for coverage of the replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a K3 prosthesis replacement.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a split-night polysomnography (PSG) attended with 
therapy. 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says an attended sleep study is not medically necessary, and the enrollee would meet criteria 
for an unattended sleep study instead. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of obstructive sleep apnea (OSA) and has been using continuous 
positive airway pressure (CPAP) for several years with benefit. The patient reports compliance and is happy 
with the device. There is a long-standing history of difficulty maintaining sleep with early morning awakening, 
for which the patient takes a sleep medication. The indicated reason for the PSG is "recurrence of 
symptoms." However, it appears the patient has had this sleep problem for years, including before and during 
treatment with CPAP. Currently the Epworth score is normal at 4. There is no download from the device to 
document usage and assess effectiveness of the device in treating sleep disordered breathing. There are no 
attempts to address sleep hygiene or assess for possible depression.  If the device is shown to be ineffective on 
the downloaded data, an attended PSG and PAP titration study may be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a split-night polysomnography (PSG) attended with therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Molecular Intelligence profile testing provided on March 
7, 2022. 
 
You asked the Plan to pay for the Molecular Intelligence profile testing. You say that this testing was medically 
necessary and should be covered. The Plan denied your request. The Plan says this testing was not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare only covers this NGS testing when patient 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and has not been 
previously tested with the same test using NGS for the same cancer genetic content.  
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 Molecular Intelligence profile testing. 
Our reviewer says that this testing is not medically necessary and reasonable in this case. Our physician 
reviewer found the enrollee is a 75 yo female with adenocarcinoma of the lung. She is status post left upper 
lung lobectomy and has completed her 4th cycle of Cisplatin/Taxotere. Per the reviewed documentation, the 
enrollee does not have recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 Molecular Intelligence profile testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Molecular Intelligence profile testing provided on March 7, 
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says medical necessity for admission to acute inpatient rehabilitation is not met. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: 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 meets LTACH admission 
criteria. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's 
needs are being met at the current facility. 
 
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 record states the enrollee is still dependent on a feeding tube and is still being 
treated for pneumonia and pulmonary edema. The enrollee appears to still unstable and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on June 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says tests not ordered by the physician who is treating the beneficiary are not 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 looked at the file and Medicare rules. The Plan contacted the referring provider, and the provider advised 
that they did not order the genetic testing. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services (0037U) provided on June 20, 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 this is medically necessary. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
Your ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a Skilled 
Nursing Facility. 
 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemotherapy regimen of carboplatin, paclitaxel, and 
pebrolizumab. 
 
You asked the Plan to pre-approve carboplatin, paclitaxel, and pembrolizumab. You say that the enrollee needs 
chemotherapy. The Plan denied your request. The Plan says this chemotherapy regimen is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 carboplatin, paclitaxel, and 
pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested 
chemotherapy regimen. Our physician reviewer found the requested drug regimen is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. This combination is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of carboplatin, paclitaxel, and pembrolizumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a chemotherapy regimen of carboplatin, paclitaxel, and 
pebrolizumab.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopic procedure provided on May 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the endoscopic procedure. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 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 an endoscopic procedure provided on May 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac catheterization. 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 no history of chest pain and recent low-risk radionuclide stress test. 
Cardiac catheterization is not supported in this 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
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 clearly benefit from IRF level of 
care and meets criteria for medical necessity. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 the enrollee is medically stable and does not need a physician's close supervision 
three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of 
chronic medical conditions. The document does not support medical necessity for admission to an IRF due to 
lack of medical complexity and lack of nursing needs and current level of function. While the enrollee would 
benefit from physical therapy, and occupational therapy the enrollee's rehabilitation needs can be safely 
provided in an alternate and low intensity setting such as in a skilled nursing facility or in-home with services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH placement for wound 
management and intravenous antibiotic therapy is needed. 
 The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 was admitted to the acute care hospital with foot infection with 
osteomyelitis requiring wound antibiotics, dialysis, and wound care. The medical record shows the enrollee still 
needs ongoing wound care and intravenous antibiotics. The enrollee appears to be stable and improving with 
current treatment and should only require short-term additional acute care services that can safely be provided 
at the current facility until more appropriate for 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 
 The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve wheelchair ramp. You say that you cannot lift your wheelchair. The Plan 
denied your request. The Plan says this is not covered by Medicare because it is for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility. 
 
 
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 the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: 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 you still need the support of two people in order to 
stand. You say your legs have become very weak. The Plan denied your request. The Plan says the SNF care is 
not medically necessary, and your needs can be met at a lower level of care such as a long-term care facility. 
 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 there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a 
practical matter, you do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.