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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 atrial flutter and a urinary tract infection.  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, in 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. 
 
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
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 group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found clinical documentation shows that you do have neurological disease with mobility and activity 
of daily living (ADL) impairments which could meet criteria (qualifying) for a group 3 power wheelchair 
however there is no specific documentation as to why you require power tilt, power recline or upgraded 
electronics (power functions with connection to the controller). 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (72141, 72146, 72148) billed for date of 
service March 11, 2022. 
 
You asked the Plan to pay for imaging services. You say that these services were rendered in an appropriate 
place of service. The Plan denied your request. The Plan says this claim was not billed with an appropriate 
place of service (POS) code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that when a patient is registered inpatient in a hospital, the correct POS code, regardless of 
where the face-to-face service occurs, is that of the appropriate inpatient POS code. 
 
The services in this case were billed with POS 22 (on campus  outpatient hospital). We find that POS code 22 
is not supported in the medical record. Specifically, the record shows that the enrollee was registered inpatient 
status from March 9, 2022, to March 15, 2022. Based on this information, we decided that Medicare billing 
rules have not been met, as these services should be billed with an appropriate inpatient POS code. Therefore, 
we decided that the Plan does not have to pay for imaging services (72141, 72146, 72148) billed for date of 
service March 11, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve seven additional visits for direct skilled nursing services of a 
registered nurse (RN) (G0299 x7). 
 
You asked the Plan to pre-approve the additional skilled nursing visits. You say that the enrollee needs skilled 
nursing to be reminded to take their medications and remove any duplicate or expired medications. You also 
say that the enrollee needs skilled nursing so they can be observed drawing up injectable medications to 
determine if they are able to draw up the correct dose. The Plan denied your request. The Plan says that the 
requested care is for convenience and does not meet criteria. 
 
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 additional skilled nursing visits. Our 
reviewer says that seven additional home health nursing visits are medically necessary. Our physician reviewer 
found the clinical documentation shows that the enrollee has active medical conditions that require the ongoing 
assessment and treatment by a professional nurse. 
 
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 additional skilled nursing visits have been met. Therefore, we decided that 
the Plan has to pre-approve seven additional visits for direct skilled nursing services of a registered nurse (RN) 
(G0299 x7).  
 
 
 
 
 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you feel Euflexxa should be approved for coverage. 
The Plan denied your request. The Plan says you have not tried nor failed the preferred drugs. 
 
 
 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 Euflexxa. Our reviewer says that 
Euflexxa is not reasonable and necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. Our 
reviewer also found that the documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, 
or Synvisc-One would likely be less effective, and/or would likely have adverse effects for you in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (29 fractions) for treatment of 
prostate cancer. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than Intensity-modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (29 fractions) for treatment of prostate cancer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary computed tomography angiography (CCTA). 
 
You asked the Plan to pre-approve a CCTA. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CCTA is covered under certain circumstances. 
 
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 CCTA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found overall, there is insufficient support in the 
peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the 
heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this enrollee's medical condition. 
 
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 CCTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a coronary computed tomography angiography (CCTA).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the emergency medical care provided 
outside the United States on July 28, 2021. 
 
You asked the Plan to provide reimbursement for the emergency medical care. You say that you feel that this is 
being denied incorrectly and that you have submitted everything that is needed. The Plan denied your request. 
The Plan says the documentation submitted does not include proof of the amount paid. As such, reimbursement 
of the requested amount cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the emergency medical care provided 
outside the United States on July 28, 2021, have been met. Specifically, though the invoice is included, there is 
no proof of payment. The wire transfer notice does not indicate the amount that was paid. The invoice only 
indicates that $120 was paid, while you are requesting reimbursement for the entire amount billed. Therefore, 
we decided that the Plan does not have to provide reimbursement for the emergency medical care provided 
outside the United States on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for 
the requested services have not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in the enrollee's 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS device (33289, C2624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 14, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of services. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 11. However, the records do not show that the specimen was collected in an office setting. This 
means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a urologist for a second opinion 
(99211, 99204) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you had TERP surgery, and your specialist 
ordered a second opinion because the provider was not able to determine the cancer in your urethra. The Plan 
denied your request. The Plan says you must receive your care from a network provider. The Plan also says 
they have participating providers that can provide the requested items 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 
an office visit with a urologist for a second opinion (99211, 99204) to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition administration kit, per day (B4224) and 
parenteral nutrition solution (B4197) provided from July 10, 2021, through July 15, 2021. 
 
You asked the Plan to pay for parenteral nutrition supplies. You say that you would like this claim reprocessed 
and approved for payment based on information you received. The Plan denied your request. The Plan says the 
benefit for services received from an out of network provider has been exhausted. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Medicare rules say that plans can require enrollees to get care from 
network providers. The contract with the Plan says that the Plan has provides some coverage for services 
rendered by an out-of-network provider. There is a $5,000 annual limit for these services.  
 
In this case, the Plan has indicated that the $5,000 annual limit for services obtained through the point of 
service benefit had already been met. Therefore, we decided that the Plan does not have to pay for parenteral 
nutrition administration kit, per day (B4224) and parenteral nutrition solution (B4197) provided from July 10, 
2021, through July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sildenafil 20MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says sildenafil 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 sildenafil 20MG tablet.  
 Benefits for the medication 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health physical therapy visits. 
 
You asked the Plan to pre-approve 6 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 6 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy 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 6 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for dates of service February 7, 
2022, to February 11, 2022. 
 
You asked the Plan to pay for procedure code H2017. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for dates of service February 7, 2022, to February 11, 2022.