Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) visits (CPT 
code G0299 x9). 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says your records do not support the need for a skilled nurse 
to make more visits. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 health skilled nursing visits. 
Our physician reviewer found you do not have documented skilled nursing needs. As such, the requested, 
ongoing, HH SN services are not medically necessary or reasonable. 
 
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 health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) visits (CPT code G0299 
x9).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urological supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON urological supplies. The Plan denied your request. The Plan says 
medically necessary care is available in-network. 
 
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 OON items/services. Therefore, we decided that the Plan does not have to pre-
approve urological supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a catheter placement. You say that the doctor has found abnormal findings 
on circulation of the heart. The enrollee is a month late with his needs already. He needs a catheter due to chest 
pains. The Plan denied your request. The Plan says the catheter placement does not meet the requirements for 
approval. 
 
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 a catheter placement. 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 a CT angiogram showing low-risk findings and an echocardiogram 
was normal. A stress test has not been performed. Guidelines do not support a need for cardiac catheterization 
in this setting. As a result, at this time cardiac catheterization 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 a catheter placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic testing) (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 
81306, 81328, 81355, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238) provided on March 16, 
2022. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report. You say that these services are payable 
by Medicare and were denied as experimental in error. You have submitted medical records for review. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for these laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneDose Genetic Response Report have not been met. This was an NGS panel that was not 
billed with a single panel code as required. Therefore, we decided that the Plan does not have to pay for the 
GeneDose Genetic Response Report (comprehensive hereditary pharmacogenomic testing) (81225, 81226, 
81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81401, 0031U, 0032U, 0033U, 
81479, 81407, 81406, 81238) provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 10, 2021, to February 13, 2021. 
 
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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 854 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH CC). 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the medical record does not include documentation to support 
SOFA score 2. The records submitted do not include documentation of sepsis. Therefore, A41.9 is not 
supported as the primary diagnosis per health plan criteria for sepsis 3, and therefore DRG 854 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 10, 2021, to February 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), an expandable 
controller (E2377) and an expandable controller harness (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the requested accessories cannot be covered as it is not 
medically necessary to control the three approved power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested items exceed the enrollee's medical needs. Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. The enrollee does not require a ventilator, or non-
proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display 
(i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or 
computer through the chair's drive control), or an attendant control. The enrollee has at least 3 power options 
on the wheelchair, but she does not need to control the power options through a joystick. She has no right upper 
extremity ataxia and her upper extremity strength supports that she can control any power options through their 
own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), an expandable controller (E2377) and an 
expandable controller harness (E2313).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. He will not tolerate the intensity of 
IRF therapies. While the enrollee may benefit from continued physical therapy and occupational therapy, the 
enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in a skilled 
nursing 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 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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee received oral medications and had stable vital signs. The enrollee does 
not require skilled nursing or therapy services on a daily basis. The enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is medically 
necessary for treatment of the enrollee's chronic obstructive pulmonary disease (COPD.) The Plan denied your 
request. The Plan says a home mechanical ventilator set in intelligent volume-assured pressure support (iVaPS) 
mode with Auto-expiratory positive airway pressure (EPAP) that could be delivered by bilevel positive airway 
pressure (BiPAP) 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has severe COPD. An arterial blood gas (ABG) done August 22, 2022, was consistent with acute mild carbon dioxide (CO2) retention.  The enrollee's circumstances at that time are 
unclear.  If this enrollee does have chronic CO2 retention, then BiPAP with average volume-assured pressure 
support (AVAPS) during sleep may be beneficial. Medicare does not cover a home ventilator when used as 
BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration as the enrollee 
needs aggressive therapy before returning home. The Plan denied your request. The Plan says he records do not 
show that the enrollee's rehabilitation needs are complex and need to be seen by a rehabilitation doctor three 
times per week for evaluation of functional and medical goals and progress. The services you need can be 
provided safely in other settings, for example, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of implant body. 
 
You asked the Plan to pre-approve the dental services. You say that the best long-term solution would be to 
remove all lower implants on the bottom and use a traditional lower denture. The Plan denied your request. The 
Plan says the service in question is not covered under the contract under any normal circumstances. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve surgical removal of 
implant body.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health care provided 
from April 19, 2022, through April 21, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $50 per 
day, for days 1 through 5 and $0 per day, for days 6 through 90 for inpatient mental health care.   
 
You have been asked to pay $100 ($50 copayment x 2 days) for the inpatient mental health care provided. 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 the inpatient mental health care 
provided from April 19, 2022, through April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 document does not support necessity for admission to an IRF. While the enrollee 
may benefit from continued physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation 
needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing facility 
(SNF). 
 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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve acute inpatient psychiatric hospitalization. You say that it is not safe to 
discharge the enrollee. The Plan denied your request. The Plan says that an inpatient level of care is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 acute inpatient psychiatric 
hospitalization. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found 
the enrollee was admitted to the acute inpatient psychiatric hospitalization on September 7, 2022, until 
September 18, 2022, with Intermittent Explosive Disorder and Intellectual Disability. At issue is September 19, 
2022, forward.  Based upon review the records provided it was expected this enrollee would improve in a 
reasonable period of time as he did have dangerousness to self and others. No auditory or visual hallucinations 
while showing aggressive behaviors. It did appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care as he was found to be quite violent 
and threatening. This enrollee did appear to require inpatient mental health treatment as he was a danger to 
himself and others while being noncompliant. It did appear that active treatment was taking place. It did appear 
that the services were reasonably expected to improve the patients condition or for the purpose of diagnosis. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient psychiatric hospitalization have been met. Therefore, we decided 
that the Plan has to pre-approve acute inpatient psychiatric hospitalization.  
 
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.