Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for infected wounds and sepsis and was discharged to skilled nursing then was discharged home. There has been ongoing weakness at 
home. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: 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 feel if the enrollee gets up and starts moving, it 
will not take as much strength to maneuver from point A to point B. The Plan denied your request. The Plan 
says based on Medicare guidelines the IRF 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 was admitted for respiratory failure and COVID-19 pneumonia. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program.  
 
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: 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 had colon surgery and are still experiencing lots 
of pain and are unable to use the bathroom on your own. You said that you need physical therapy to walk again 
and to be able to get strong enough to care for yourself. The Plan denied your request. The Plan says you do not 
meet SNF criteria and your needs can be met at a lower level of care. 
 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 SNF 
care is not medically necessary. Our physician reviewer found there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. Records do not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care 
or respiratory care. While you do have skilled therapy needs, there is no documentation that daily skilled 
services are required. You are walking household distances with a wheeled walker with stand-by assistance and 
are stand-by assist for transfers. Provided records do not document a significant decline in your functional 
status to necessitate daily inpatient skilled therapy services. There is no documentation that you need the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate 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 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: 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 the physician recommended physical therapy for you 
to do in an inpatient rehabilitation facility. The Plan denied your request. The Plan says based on Medicare 
guidelines the IRF 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 you were admitted for a surgical repair of an olecranon fracture and non-surgical 
management of an acetabular fracture after a fall. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation 
of a need for an intensive rehabilitation program. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on 
March 29, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you have been in mental health counseling with this 
provider for 5 or 6 years. You say that you are on a limited income and seeking partial reimbursement. The 
Plan denied your request. The Plan says the service was 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 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 psychotherapy provided by an out-of-network 
provider on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a platelet rich plasma (PRP) injection provided to the 
enrollee on March 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was informed that these were experimental treatments. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at present, the evidence is insufficient to determine the effects of this injection on health outcomes 
for osteoarthritis. The existing evidence and lack of accepted standards of medical practice for PRP injections 
do not meet the requirement of medically reasonable and necessary. Therefore, PRP injections and PRP combined with stem cells for musculoskeletal injuries and/or joint conditions, whether primary or adjunctive 
use, are not medically reasonable and 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 pay for a platelet rich plasma (PRP) injection provided to the enrollee on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing (87798, 
87640, 87481) provided on March 28, 2021. 
 
You asked the Plan to pay for urine PCR testing. You say that this testing is faster and more accurate which 
allows for earlier treatment. The Plan denied your request. The Plan says the standard of care for the evaluation 
of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven 
and is therefore 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 pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for evaluation for a urinary tract infection (UTI) is a urinalysis with urine culture. PCR testing is considered unproven and not medically necessary. 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing (87798, 87640, 87481) provided on March 
28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program provided on January 20, 2022. 
 
You asked the Plan to pay for ophthalmological services: medical examination and evaluation, with initiation 
or continuation of diagnostic and treatment program. You say that the enrollee relies on the nursing facility 
staff for all of his needs. You say a provider performing services in a nursing home facility is not responsible to 
obtain authorization. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-
of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 ophthalmological services: medical examination and evaluation, 
with initiation or continuation of diagnostic and treatment program provided on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam of the spine, an x-ray exam of the pelvis, an x-
ray exam of the hip and x-ray services provided on March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray exam of the spine, an x-ray exam of the pelvis, an x-ray exam of the hip 
and x-ray services. You say that you have already requested the prior authorization number and submitted the 
claim along with the number, but the claim denied for service needing authorization. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 x-ray exam of the spine, an x-ray exam of the 
pelvis, an x-ray exam of the hip and x-ray services provided on March 7, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Myelodysplastic Disorder Panel (MDS) (CPT code(s): 81450, 
81479x10-MISCTEST, 81219, 81403-DNMT3A, 81236, 81120, 81120, 81311, 81333, 81334, 81351). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the doctor's notes do not show the enrollee has an approved condition for this kind 
of testing. 
 
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 physician reviewer 
found National Comprehensive Cancer Network (NCCN) guidelines allow molecular testing in a patient with 
pancytopenia to rule out MDS; thus, the MDS panel should be approved per the LCD. 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 been met. Therefore, we decided that the Plan has to pre-approve 
Myelodysplastic Disorder Panel (MDS) (CPT code(s): 81450, 81479x10-MISCTEST, 81219, 81403-
DNMT3A, 81236, 81120, 81120, 81311, 81333, 81334, 81351).  
 
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 pay for medical services provided on April 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that this patient chose to come to your 
facility because he has been there in the past. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
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 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 medical services provided on April 22, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator with settings that could be 
delivered by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
for this member with COPD is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found while the enrollee has COPD, the documentation does not support a diagnosis of chronic 
respiratory failure. The case file does not contain documentation of trial and failure of BiPAP/AVAPS or 
evidence that this would likely be ineffective 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological or neuropsychological services provided on 
February 3, 2022. 
 
You asked the Plan to pay for psychological or neuropsychological services. You say that you called the Plan 
and were told you are participating. The Plan denied your request. The Plan says the member saw an out-of-
network provider when there are in-network providers that could provide the same service. 
 
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 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 psychological or neuropsychological services provided on 
February 3, 2022.
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 the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting. The Plan denied your request. The Plan says the enrollee does not require an 
intensive level of therapy requiring physician oversight and 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 enrollee was admitted for respiratory failure and COVID-19 pneumonia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for immunotherapy injections provided on 
April 13, 2022. 
 
You asked the Plan to waive the copayment for immunotherapy injections. You say that you do not feel you 
should have to pay a higher copayment because Medicare chose to raise the allowed amount when it has been 
$10.93. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 a $30 
copayment per visit with an in-network specialist.  
 
You have been asked to pay $11.17, which is less than the $30 copayment for immunotherapy injections. 
Immunotherapy injections fall within the physician/practitioner services, including doctors office visits 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 immunotherapy injections provided on April 
13, 2022.