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

 
We decided that the Plan does not have to pay for laboratory services (80053, 85025, 80061, 81001, 82570, 
82043, 82607, 82306, 84443) provided on February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee moved to Utah in February 2022 
and sought care with the requested provider. The enrollee handed over her Medicare card and you did not know 
she was still covered by a different plan. The Plan denied your request. The Plan says the service was obtained 
or sought out of the service area. Enrollees must receive care from network providers. 
 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 laboratory services (80053, 85025, 80061, 81001, 
82570, 82043, 82607, 82306, 84443) provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 15 fractions of intensity-modulated radiation therapy (IMRT) with 
image-guided radiation therapy (IGRT) and a boost phase of 4 fractions of IMRT with IGRT. 
 
You asked the Plan to pre-approve IMRT with IGRT. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that there is no research showing that the enrollee's cancer 
responds better to this treatment that to the other treatment the Plan recommends, which is 3-dimensional (3D) 
conformal. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT with IGRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found it is safe to say that IMRT is not experimental, but rather a useful tool available to radiation 
oncologists to potentially reduce toxicity and improve the lung, heart, and skin dose distributions. In light of 
the dosimetric improvement with IMRT in the enrollee, as well as the most recent update of the American 
Society for Radiation Oncology's (ASTRO's) Choosing Wisely list, this would be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT with IGRT have been met. Therefore, we decided that the Plan has to 
pre-approve 15 fractions of intensity-modulated radiation therapy (IMRT) with image-guided radiation therapy 
(IGRT) and a boost phase of 4 fractions of IMRT with IGRT.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided at a 
tertiary level of care. 
 
You asked the Plan to pre-approve the PT services. You say that the facility you are requesting to go to is the 
closest to your home. You say that you have a worsening and high level of pain. You also say that you cannot 
travel out to the current authorization provider that is 30 minutes away. The Plan denied your request. The Plan 
says there are in network providers available. The Plan also says there is not a medical need to go to a tertiary 
level provider. 
 
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 PT services. Our reviewer says that 
the requested PT visits at a tertiary facility are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate that the requested physical therapy 
services at a tertiary care center is an appropriate level of care for treatment of the enrollees medical condition. 
Therefore, the reviewer found that the requested is not 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 the PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy (PT) services to be provided at a tertiary level of care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services performed by a qualified physical therapist in the 
home health or hospice setting (G0151, G0157) provided on March 15, 2022, to April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that medical records have been submitted to 
support medical necessity and payment reconsideration. The Plan denied your request. The Plan says health 
plans can require enrollees to get care from network providers. They pay for care from out-of-network 
providers only in cases involving emergencies, out-of-area urgent care, and pre-approved care. The Plan 
determined that the services rendered to the member are not urgent or emergent, nor were they approved in 
advance by a network provider. 
 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 services performed by a qualified physical 
therapist in the home health or hospice setting (G0151, G0157) provided on March 15, 2022, to April 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vilazodone tablets. 
 
You asked the Plan to pre-approve Vilazodone tablets. You say that Vilazodone, 40 mg, one and a half tablets 
daily, has been the only regimen that has been found to help minimize the enrollee's depressive symptoms. The 
Plan denied your request. The Plan says Vilazodone 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 Vilazodone tablets.   
Benefits for Vilazodone tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says there is 
no documentation that the enrollee will benefit from and improve with LTACH management. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with chronic inflammatory 
demyelinating polyneuropathy (CIPD) and pancytopenia requiring transfusions and complicated by a thrombus 
treated with heparin. Recent notes describe the enrollee is still on heparin, but with the CIPD at baseline and 
tolerating the diet. The enrollee 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 soon.  
 The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing, on behalf of the 
enrollee, the pre-service denial of long-term acute care hospital admission. The Plan denied your request. The 
Plan says admission to LTACH was denied as not meeting criteria, is not medically necessary, and continued 
acute hospital stay was offered, until the enrollee 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 pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital for elective coronary artery 
bypass graft surgery complicated by cerebral vascular accident. The enrollee was not a tPA candidate but was 
treated with tube feeds and mechanical ventilation support. Recent notes describe the enrollee was still on 
dobhoff with plans for percutaneous endoscopic gastrostomy placement, with plans for ongoing physical, 
occupational, speech therapy and with two failed weaning trials over the past few weeks. The enrollee appears 
to have stable vitals but with unstable feeding source and still requiring weaning.  The enrollee 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 soon. The enrollee is receiving appropriate care 
at the present setting. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they 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 the LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says they don't have a record from the prescriber that 
shows the enrollee has tried on of the preferred drugs and it hasn't worked, or that the enrollee has medical 
reasons that prevent using one of them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug 
Remicade or Avsola before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cryoablation of breast cancer provided to the enrollee on 
March 10, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services have denied, as experimental and investigational services are not covered. 
 
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 this request is not considered a standard of care in the primary treatment of breast cancer. The use is 
not support by the National Comprehensive Care Network (NCCN) guidelines or the medical literature. Trials 
are ongoing, and no phase III data is available. 
 
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 cryoablation of breast cancer provided to the enrollee on March 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided April 7, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that the date-of-service should be reported as the date the specimen was 
collected. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. 
The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, April 7, 2022. Based on this information, we decided that 
Medicare rules for coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx (F1CDx) testing (0037U) provided April 7, 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 physician services provided on May 25, 2022. 
 
You asked the Plan to pay for physician services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 physician services provided on May 25, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require can safely be received at present inpatient 
rehab facility. 
 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. There 
are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do 
not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. Our physician reviewer found that 
your condition does not meet Medicare criteria for SNF 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 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 continuous glucose monitor (CGM) supplies for the 
enrollee. 
 
You asked the Plan to pre-approve CGM supplies. You say that these are medically necessary. The Plan denied 
your request. The Plan says that the member is only taking 1 daily insulin injection. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor (CGM) supplies for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the patient's needs would be considered custodial. 
 
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. The 
member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable 
and can receive further rehab services at a lower level of care. Although further rehab services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 7, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the services 
were not urgent or emergent in nature and the services could have been rendered by a Plan participating 
provider. 
 
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 
service 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 physician's services provided on March 7, 2022.