Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs skilled nursing to progress with 
physical therapy and needs care to due to a single family at home. The Plan denied your request. The Plan says 
the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
long-term care facility or other outpatient setting. 
 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 that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. The enrollee does 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient 
in parallel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 31, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 
81328, 81335, and 81355.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that you have submitted medical records to support 
payment. The Plan denied your request. The Plan says unauthorized, out-of-network services are 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 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 the duplex scan provided on June 17, 2022, by an out-of-network 
(OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had a change in clinical status or new signs and symptoms. 
 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 documentation does not point to a change in status that would support the medical 
necessity of a repeat transthoracic echocardiography (TTE) at this time. Clinical guidelines do not support 
repeating a TTE with no intervening change in clinical status or new signs, symptoms or physical findings. In 
summary, there is no supportive evidence for the medical necessity of repeat TTE 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 transthoracic echocardiography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have submitted documentation to support 
payment. The Plan denied your request. The Plan says unauthorized, out-of-network 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 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 the office visit provided on June 14, 2022, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need to be in safe and supervised 
environment to meet your needs. The Plan denied your request. The Plan says clinically the enrollee's condition 
does require daily skilled services at an inpatient skilled nursing facility (SNF) 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 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 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 LTACH services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from February 3, 2022, 
to February 18, 2022. 
 
You asked the Plan to pay for the SNF services. You say that these services were authorized and should be 
covered. The Plan denied your request. The Plan says that you billed because the patient driven payment model 
(PDPM) code submitted on the claim is inconsistent with what was authorized.  In addition, the Plan says that 
the member no longer appears to meet Medicare criteria for SNF care. 
 
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 Plan's denial rationale references two issues, neither of which were 
supported in the case file documentation that the Plan submitted to us.  First, the Plan contends that the PDPM 
code on the claim doesn't match the authorization.  However, the Plan has failed to provide any proof that the 
authorization was limited to a specific PDPM code.  In fact, the letter that the Plan issued to you with the 
authorization approval is completely silent on the issue of a PDPM code.  As such, the Plan has failed to 
provide adequate documentation that the authorization was limited to a specific PDPM code.  Second, the Plan 
contends that the member no longer met Medicare SNF coverage criteria and could have transitioned to a lower 
level of care.  The Plan has provided absolutely no support for this assertion as it has failed to supply any 
medical records at all in the case file it submitted to us.  Without records, we cannot ascertain how the Plan 
came to this conclusion.  The burden is on the Plan to provide documentation to support its denial.  It has failed 
to do so in this case. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services 
provided from February 3, 2022, to February 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the clinic visit. You say that this was a follow-up visit after discharge from the 
hospital The Plan denied your request. The Plan says unauthorized, out-of-network 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 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 the clinic visit provided on June 13, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on June 21, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the medical records support the necessity for this service. 
The Plan denied your request. The Plan says unauthorized, out-of-network services are 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 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 the x-ray provided on June 21, 2022, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve Trulance. The Plan denied your request. The Plan says Trulance is a self-
administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.  
 
Benefits for Trulance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says unauthorized, out-of-network 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 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 medical services provided on April 22, 2022 by an 
out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee does not 
have complex rehabilitation needs. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for flank pain, hydronephrosis and pleural effusion. Her 
medical problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you need more trips to go to the doctors. The 
Plan denied your request. The Plan says you have used the allotted trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The file shows that you have used 24 one-
way trips Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the prostate cancer screening (G0103) provided on May 6, 2022. 
 
You asked the Plan to pay for the cancer screening. You say that this should be covered. The Plan denied your 
request. The Plan says that a prostate cancer screening is covered once every 12 months. The Plan also says 
that the benefit has been exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record does not show that the Plan paid for this service 
previously. Therefore, we decided that the Plan has to pay for the prostate cancer screening (G0103) provided 
on May 6, 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 radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria ar emet. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have chronic low back pain and 
have had physical therapy. You had diagnostic medial branch block (MBB) injections on November 30, 2021 
that provided relief for one to two days. The Medicare rules require two sets of MBBs that provide at least 80 
percent pain relief. This has not been performed; therefore, the RFA is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
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. The Plan denied your request. The Plan says based on a review of 
the clinical information provided the request has been denied as it is not reasonable and 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 a stroke. 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting long term acute care 
hospital admission.  The Plan denied your request. The Plan says that criteria for admission to the LTACH 
have not been met. 
 
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 that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 LTACH services.