Persius/hicric huggingface dataset:
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 it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the records received, shows the enrollee's condition does 
not meet Medicare guidelines. The enrollee is currently in a long-term care facility. The enrollee does not have 
complex rehabilitation, medical, and nursing need. The enrollee does not need 3 hours of therapy per day or 15 
hours per week. The enrollee's needs can be met at home with home health services, an assisted living facility, 
or a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for COVID pneumonia, congestive heart failure, and urinary tract infection and was 
transferred to skilled nursing on July 27, 2022. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee 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 enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: 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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 acute inpatient rehabilitation admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria and would benefit from the higher level of care than the current skilled nursing facility. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the 
requirements for approval. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
does not enrollee require services at the LTACH that are not available at the acute care hospital where care is 
currently being provided. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on December 15, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the enrollees 
treating physician indicating that the enrollee has decided to seek further cancer treatment. The records do not 
include a treatment plan for the enrollees condition. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the FoundationOne testing provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections. 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the repeat injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if trigger point injections are performed more than 
three sessions in a three (3) month period, the reason for repeated performance and the substances injected 
should be evident in the medical record. 
  
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 injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found the documentation fails to indicate 
that the requested additional injections are medically necessary due to the member having received 100% relief 
of pain from previous injections. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve trigger point injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on October 7, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says the records 
reviewed do not indicate that the service represented by code 90832 was performed twice by the same provider. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 9, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for psychotherapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis, sagittal control, with rigid 
anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces 
intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, 
shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf (L0648). 
 
You asked the Plan to pre-approve a lumbar-sacral orthosis. You say that the enrollee is scheduled for surgery 
and the orthosis is needed for completion after surgery. The Plan denied your request. The Plan says these 
braces are fitted and applied for use in the days after surgery prior to ambulation while still in the hospital and 
prior to discharge. The Plan also says payment for a spinal orthosis is also included in the payment to a hospital 
stay. 
 
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 a lumbar-sacral orthosis have not been met. The Plan confirms that payment for a spinal orthosis is 
included in the payment for the hospital stay. Therefore, we decided that the Plan does not have to pre-approve 
a lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from 
sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral 
discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, 
prefabricated, off-the-shelf (L0648).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 routine transportation trips. 
 
You asked the Plan to pre-approve an additional 100 routine transportation trips. You say that you need 
transportation to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 
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 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. 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 an additional 100 routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh (78815) and fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries (A9552) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a PET scan and a fluorodeoxyglucose procedure. You say that you need this 
procedure to take place at the requested facility since the provider is doing a Y90 surgery to ablate your liver 
cancer tumors. You also say this surgery must take place within a week or two or he will die. This procedure is 
taken right after Y90 surgery to make sure the surgery is a success. The Plan denied your request. The Plan 
says you must use network providers to get your medical care and services. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (78815) and fluorodeoxyglucose f-18 
fdg, diagnostic, per study dose, up to 45 millicuries (A9552) to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee has not had any syncopal episodes. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has no 
history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on ECG monitoring. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 an implantable loop recorder (ILR) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the lower denture is broken, and you 
cannot eat well. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 2, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation mileage to get to a specific 
medical facility. 
 
You asked the Plan to provide additional routine transportation mileage. You say that you need to get to this 
facility, and this transportation is necessary. The Plan denied your request. The Plan says the requested trip is 
longer than what is covered by your benefit. 
 
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 routine transportation when a trip is requested to or from a Plan-approved location within 
50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. The requested location is more than 50 
miles from your home. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to provide additional 
routine transportation mileage to get to a specific medical facility.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for DPYD (dihydropyrimidine dehydrogenase) lab testing (81232) 
provided on March 10, 2022. 
 
You asked the Plan to pay for DPYD gene analysis. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that this test was not billed in accordance with Medicare rules. The 
Plan argues that the enrollee had Tempus xT Solid Tumor panel testing billed with multiple codes, including 
81232. Code 81232 was submitted on a separate claim form than the other codes, but testing was performed on 
the same specimen. 
 
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 Plan did not provide evidence of the other claim which was 
submitted for additional codes for this panel. Without this information, we cannot verify that a complete panel 
was billed with multiple genes rather than one code. Therefore, we decided that the Plan has to pay for DPYD 
(dihydropyrimidine dehydrogenase) lab testing (81232) provided on March 10, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychiatric diagnostic evaluation (90791) 
psychotherapy services (90834) provided March 1, 2022 to April 11, 2022 by an out of network provider. 
 
You asked the Plan to reimburse you for the psychiatric services. You say that since this is a PPO it is your 
understanding that you could go out of network. You paid out of pocket $900 for 4 sessions. When you 
submitted the claims, you were only reimbursed $432.32. You paid as you were advised and now you are not 
being reimbursed. The Plan denied your request. The Plan says the claim was processed with the correct cost 
share applied per the Evidence of Coverage. 
 
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 30% 
coinsurance for out of network mental health services.  
 You are asking for additional reimbursement for the psychiatric services. The records show that the Plan paid 
you their share of the allowed amount totaling $432.32, minus your coinsurance amount of $185.23. For dates 
of services March 1, 2022, March 28, 2022 and April 4, 2022 the total charges was $225.00. The Medicare 
allowed amount was $172.71 and the Plan paid $120.90. Your coinsurance was $51.81. For date of service 
April 11, 2022 the total charges was $225.00 and the Medicare allowed amount was $125.66 and the Plan paid 
$69.54.  Your coinsurance was $29.80.  The health Plan contract says that it is best to ask an out of network 
provider to bill the Plan first. But if you have already paid for the covered services, the Plan will reimburse you 
for their share of the cost for covered services. You were paid the Plans share of the cost. The psychiatric 
services fall within the Outpatient mental health care 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 reimburse 
you for psychiatric diagnostic evaluation (90791) psychotherapy services (90834) provided March 1, 2022 to 
April 11, 2022 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist (99203) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need to have your treatments. If you do not 
get the shots, you will get sick, and it will slow down your eating and walking. The Plan denied your request. 
The Plan says you must use network providers to get your medical care and services. There are providers 
available in your network who can care for you. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with an oncologist (99203) to be provided by an out-of-network (OON) provider.