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

 
We decided that the Plan does not have to pay for the services you received from an out-of-network provider 
from January 5, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
contracted with the Plan. 
 
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 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 services you received from an out-of-network provider from 
January 5, 2021, to October 21, 2021.
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 LTACH is the most appropriate level of 
care for the enrollee at this time. You say that the enrollee should not be discharged to a lower level of care, as 
she has had multiple complications during this hospitalization; and you would like to prevent readmission to 
the short-term acute care hospital. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 you would like IRF care in order to return to being 
independent The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission 
to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that you 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: 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 7, 2021, to December 6, 2021. 
 
You asked the Plan to pay for home health services. You say that the RAP was submitted, and the appeal 
stands on a factual and legal basis. The Plan denied your request. The Plan says the Rap claim was submitted 
past the 5-day requirement. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care.. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 7, 2021, to December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging service provided on October 21, 2020. 
 
You asked the Plan to pay for the imaging service. You say that the claim was submitted once the correct 
information was obtained. The Plan denied your request. The Plan says the claim was submitted over a year 
past the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the imaging service was not filed until November 8, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the imaging service provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub (E1399). 
 
You asked the Plan to pre-approve a walk-in tub. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to a Long-Term Acute Care Hospital. 
 
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. The patient 
appears to have improved some but is somewhat unstable and requires short-term additional acute care hospital 
services to further stabilize the patient that can be safely completed at the current facility until appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the patient requires that are not already available and 
covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF admission is not medically necessary. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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: 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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee's status is unstable and critical. You say 
that the enrollee is current receiving medically necessary acute and critical care. The Plan says that the enrollee 
does not have clinical indications that cannot be appropriately treated in the current hospital. 
 
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 for acute respiratory failure 
related to pleural effusions, and chronic heart failure exacerbation. He was treated with chest tubes, intubation, 
and diuresis. A trach was placed. Recent notes describe the enrollee as having been weaned to 40L oxygen via 
trach but is still requiring chest tubes with high output. The enrollee appears to be improved somewhat but is 
still unstable and should only require short-term acute care services to safely complete care until more stable 
for discharge to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that the enrollee has tried and failed oral Methotrexate. 
The Plan denied your request. The Plan says the enrollee has not tried and failed Remicade, Inflectra, 
Infliximab, or Simponi Aria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Actemra. Our physician reviewer found 
that the enrollee has a diagnosis of Rheumatoid arthritis without rheumatoid factor, multiple sites. The Plan 
requires a trial of Remicade, Inflectra, Infliximab, or Simponi Aria before they will approve the requested drug. 
The documentation does not support that the Plan's required drugs have been tried and failed. The 
documentation does not support that the Plan's required drugs would likely be less effective or would likely 
have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
February 13, 2020, through February 29, 2020, billed with code GDXE1. 
 
You asked the Plan to pay for the SNF services as billed. You say that this was billed correctly based on the 
enrollee's condition. The Plan denied your request. The Plan says the documentation is not sufficient to approve 
the billed HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is based on a HIPPS 
code with five case-mix groups which are assigned based on the information from the MDS assessment. The 
rules say that for reporting functional abilities in Section GG, facilities must assess self-care performance based 
on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or 
family documented in the residents medical record during the three-day assessment period. It is expected that 
an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day 
assessment period. The rules for Section I require that only diagnoses with physician confirmation within the 
60 days prior to admission, and that the diagnosis be active within the last 7 days. 
 
We looked at the file and Medicare rules. The information received did not include any physician records to 
support diagnoses, nor any assessments from the first 3 days of the stay to support the reported functional 
abilities. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) services provided from February 13, 2020, through February 29, 2020, billed with code GDXE1.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast. 
 
You asked the Plan to pre-approve Reclast. The Plan denied your request. The Plan says lab notes and renal 
function are not noted. 
 
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 Reclast. Our physician reviewer found 
that you have a history of a kidney transplant and low bone mineral density (BMD). You were treated with 
Reclast in 2020.  A bone density scan in 2021 shows significant improvement in the BMD in the lumbosacral 
spine, but no significant change in the hip. There are no follow up notes regarding the BMD or labs from 2021 
or 2022. Without recent creatinine level and calcium, it is hard to say that the use of Reclast now is medically 
safe and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous nerve ablation procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
little evidence to suggest this is an appropriate procedure for back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that an Intracept intraosseous nerve ablation procedure was requested. 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 requested services. Our physician reviewer found that the 
Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the 
request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intraosseous nerve ablation procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing for Lynch syndrome coded as 81319, 
81317, 81300, 81298, 81297, 81295, 81294 and 81292 provided May 3, 2021. 
 
You asked the Plan to pay for genetic panel testing. You say that your doctor asked the genetic testing be done 
because he felt you were high risk for colon cancer. The Plan denied your request. The Plan says the service 
does not meet medically necessity coverage 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 pay for genetic panel testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of tubular adenomas, sessile adenomas.  Her provider has recommended genetic panel testing for Lynch syndrome coded as 81319, 81317, 81300, 
81298, 81297, 81295, 81294 and 81292 provided May 3, 2021. Genetic Testing for Lynch Syndrome: tumor 
screening results (IHC or MSI) are abnormal. History of colorectal cancer. History of uterine (endometrial 
cancer) before age 50.  History of multiple primary cancer diagnoses. Several family members have had 
cancers related to Lynch syndrome. The review has determined that the items/services at issue in this case are 
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 genetic panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic panel testing for Lynch syndrome coded as 81319, 81317, 81300, 81298, 
81297, 81295, 81294 and 81292 provided May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid you purchased from an out-of-network 
provider on November 18, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you believed this provider was part of the network 
and you purchased an approved hearing aid. The Plan denied your request. The Plan says hearing aids 
purchased from an out-of-network provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan will cover 
certain hearing aids when purchased from a network hearing provider.  You are responsible for all costs for 
hearing aids not purchased from a network provider. Records show that the provider from whom you received 
this hearing aid is not a network hearing provider with the Plan. Therefore, we decided that the Plan does not 
have to pay for the hearing aid you purchased from an out-of-network provider on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 2, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on August 2, 2021.