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

 
We decided that the Plan does not have to pre-approve an ophthalmology visit (99205) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network ophthalmology visit. You say that this service is 
medically necessary. 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
ophthalmology visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for durable medical equipment 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception. The Plan denied your request. The Plan says there 
is no network deficiency. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you use an out-of-network provider, your share of the costs for covered services may be 
higher. 
 
 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. Although you have out-of-network benefits, your 
share of the costs may be higher. We found no exception that would require the Plan to pre-approve an in-
network excpetion. Therefore, we decided that the Plan does not have to pre-approve an in-network exception 
for durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) for lymphedema 
assessment(s) (93702). 
 
You asked the Plan to pre-approve BIS. You say that there are clinical documents and articles to support the 
use of this testing, and this service is necessary. The Plan denied your request. The Plan says there is little 
evidence in medical literature to suggest that this is an appropriate test to evaluate for lymphedema. This 
testing is less accurate than other testing modalities and is considered experimental and investigational. 
Therefore, this service is not medically necessary by Medicare standards. 
 
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 BIS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a 
standard of care for prevention and treatment. Assessment and follow-up is indicated for high risk patients. 
However, this enrollee with Ductal carcinoma in situ (DCIS) and no lymph node dissection is not considered 
high risk. The service was 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 BIS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve bioimpedance spectroscopy (BIS) for lymphedema assessment(s) (93702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 10, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is a statutorily excluded 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on December 
10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says the device is considered unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). This request is for a 
CardioMEMS pulmonary pressure sensor implantation to help improve fluid management and symptoms. 
There remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
 
 
 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 a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the IRF services because the 
enrollee's condition meets full criteria for admission to IRF. The Plan denied your request. The Plan says the 
medical records and the enrollee's condition does not meet Medicare guidelines of IRF services. The enrollee 
does not need 2 hours of therapy per day or 15 hours per week. The enrollees needs can be received in another 
setting such as home health services or a long-term care 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, the documentation doesnt support that she would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain her functional status. The enrollee can receive 
further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that your condition has gotten worse. The Plan 
denied your request. The Plan says you do not meet the criteria. 
 
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.  
 
We looked at the file and the rules. The medical records provided show that the wheelchair is necessary for 
independent mobility in the community. The records do not show that you have a mobility limitation that 
impairs your ability to participate in mobility-related activities of daily living in the home. The requested 
wheelchair 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 
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the upper limb orthosis (L3670) provided on February 2, 2022. 
 
You asked the Plan to pay for the upper limb orthosis. You say that this device should be covered by the Plan 
with the appropriate cost share applied. The Plan denied your request. The Plan says that an identical device 
was provided in May 2021 which is within the reasonable useful lifetime where a replacement item will not be 
covered. 
 
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, although the Plan has indicated that an identical upper limb orthosis 
was provided in May 2021, no evidence was provided to indicate that an identical upper limb orthosis was 
actually provided in May 2021. Without a claim form or some other document to prove the Plan paid fort this 
orthosis, there is no way to confirm the Plans argument. Therefore, we decided that the Plan has to pay for the 
upper limb orthosis (L3670) provided on February 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) orthopedic surgeon. 
 
You asked the Plan to pre-approve an office visit. You say that the Plan's recommended in-network providers 
do not do difficult orthopedic knee replacements. The Plan denied your request. The Plan says the services 
have been requested out-of-network and 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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services.  
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-
network (OON) orthopedic surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on January 24, 
2022. 
 
You asked the Plan to waive the copayment for lab tests. You say that you paid a $40 copayment and do not 
think you should be charged for the lab tests. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment per day for lab tests.  
 
You have been asked to pay $10 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for laboratory testing provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L3, L4, L5 medial branch blocks (MBB) 
without sedation (64493, 64494). 
 
You asked the Plan to pre-approve the injection. You say that the bilateral L3, L4, L5 medial branch block will 
help relieve this enrollee's pain. This procedure is medically necessary as a diagnostic tool in order to 
determine if the enrollee's pain is originating from a facet joint. The Plan denied your request. The Plan says the records do not show that the injections are medically necessary because the enrollee had good relief from 
prior radiofrequency ablation at the requested levels on one side. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had successful prior RFA. The enrollee does not need repeat diagnostic blocks, but 
rather repeat RFA. The request for diagnostic blocks 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral L3, L4, L5 medial branch blocks (MBB) without sedation (64493, 64494).
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 it is harder for you to get around and you need 
therapy for your legs. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
Medicare guidelines of IRF services. The enrollee could receive the care in another setting such as a skilled 
nursing facility, outpatient setting, or home health 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over 7 consecutive days. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy provided in an inpatient rehabilitation facility. The enrollee would likely benefit 
from physical and occupational therapy given his decline in function. However, he does not require the 
intensity of therapies provided in the acute inpatient rehabilitation 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 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 pay for long term acute care hospital (LTACH) services. 
 
You asked the Plan to pay for the LTACH services. You say that he is intimately familiar with the patient's 
condition and the capabilities of the short-term acute care hospitals in sub-acute inpatient providers in the 
community. You also say that it is of your professional opinion that the enrollee should be admitted 
immediately to the IRF facility for aggressive renal management, long-term intravenous (IV) antibiotic therapy 
to treat his infections, daily labs, daily provider visits, aggressive nutritional interventions for his malnutrition, 
and management of his other complex medical conditions with an aggressive regimen of physical 
rehabilitation. The Plan denied your request. The Plan says admission to LTACH did not meet criteria, is not 
medically necessary, and continued acute hospital stay was offered, until the member could discharge to a 
lower level of care. 
 
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 pay for 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 patient appears to be stable and improving, and should only require short-term additional acute care services that can safely be administered at the current facility until more appropriate for a lower level 
of care. Our physician reviewer also found that there are no services at the LTACH that the patient requires that 
are not already available and covered 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 pay for long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Hyalgan injection for unilateral primary osteoarthritis, right knee. 
 
You asked the Plan to pre-approve Hyalgan injection. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says that the criteria has not been met. 
 
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. the case file received was not complete. Only the 3 pages of the RBDF 
(reconsideration background data form) was received. A request for the complete case file was sent to the 
health Plan on July 20, 2022. With a due date of July 22, 2022. As of the date of this letter, the plan has not 
responded to our request and/or submitted the required information Therefore, we decided that the Plan has to 
pre-approve Hyalgan injection for unilateral primary osteoarthritis, right knee.  
 
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 an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the member does not appear to meet 
Medicare criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 Clinical documentation states that patient is currently receiving home health care therapy and would continue to benefit from skilled therapy however there is no documentation that would 
support multi-disciplinary rehabilitation on an inpatient basis in acute 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 an acute inpatient rehabilitation facility (IRF) admission and services.