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

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to the LTACH. 
 
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 with acute respiratory failure.  The record indicates that the 
enrollee continues to require critical care services and is not clinically stable. The enrollee continues to receive 
acute care services and these have not been denied.  The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied. 
 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic exercises used to improve strength and 
endurance (97110 x 8), and manual techniques (97140 x 8). 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you were denied physical 
therapy. You say that your knee is in bad shape. You say that you can barely walk. You also say that no 
physical therapy does not make sense. The Plan denied your request. The Plan says the provided 
documentation does not indicate that clinical progress has been made. The Plan also says that the requested 
services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the provided documentation indicates that you have 
previously been treated with outpatient therapies. The reviewer found that there is no documentation of a recent 
injury or decline in function. Therefore, the reviewer found that additional therapy services are not an 
appropriate duration and frequency for treatment of your medical condition and therefore are 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 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve therapeutic exercises used to improve strength and endurance 
(97110 x 8), and manual techniques (97140 x 8).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 therapeutic continuous glucose 
monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor and supplies. You say that you feel 
that the service should be covered, or the copay should be waived. You would like to be reimbursed for the 
$149.99 for the 28 day supply you paid for out of pocket. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria as the records show that the enrollee does not use insulin 3 or more times a 
day and only checks their blood sugar once day. 
 
 
 
 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 
therapeutic continuous glucose monitor (CGM) and supplies.
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 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 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 there are no services available at the LTACH that you require 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 your diagnosis and condition 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
 
 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder detect test provided to the enrollee on 
September 23, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder detect test provided to the enrollee on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of a wireless pulmonary artery 
pressure sensor (93264) provided on November 14, 2019. 
 
You asked the Plan to pay for the remote monitoring of a wireless pulmonary artery pressure sensor (93264). 
You say that the patient was not on hospice on this date of service and recoupment was invalid. You say that 
the claim should be reviewed and paid. The Plan denied your request. The Plan says the enrollee was an 
inpatient at the time of service and the claim was billed with place of service 11. The Plan also says that the 
procedure code was billed without the correct modifier. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93264 is remote monitoring of a wireless pulmonary 
artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure 
recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care 
professional. 
 
We find that CPT code 93264 is not supported in the medical record. Specifically, the enrollee was an inpatient 
on the date of service, but POS 11 (office) was billed. Based on this information, we decided that Medicare 
rules for coverage of the remote monitoring of a wireless pulmonary artery pressure sensor (93264) have not 
been met. Therefore, we decided that the Plan does not have to pay for the remote monitoring of a wireless 
pulmonary artery pressure sensor (93264) provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BRCA1 and BRCA2 genetic testing services. 
 
You asked the Plan to pre-approve the testing services. You say that this testing service is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria for BRCA testing is listed 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 the testing services. Our reviewer says 
that the requested genetic testing services are not medically reasonable and necessary. Our physician reviewer 
found in this case, there is no family history presented of cancer. The criteria listed that specifies the 
indications for BRCA testing have not been met. The requested service cannot be recommended. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the BRCA1 and BRCA2 genetic testing services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services provided to the enrollee 
from August 18, 2021, to September 15, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says the enrollee's condition has improved, and they are no longer a threat to themselves or 
others. 
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on a review 
of the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond 
the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The health 
plans denial of continued inpatient psychiatric services appears appropriate. 
 
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 pre-approve inpatient mental health services provided to the enrollee from August 18, 2021, to 
September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 28, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 referring provider 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 the laboratory services provided on August 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 6, 
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 this claim does not meet coding standards. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied codes are not supported in the medical record. Specifically, the records clearly show 
that these laboratory services were related to the treatment of end-stage renal disease (ESRD). Therefore, these 
services cannot be reported separately by the laboratory, and are the responsibility of the dialysis center. 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 laboratory services provided to the enrollee on 
October 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on October 25, 2021. 
 
You asked the Plan to pay for outpatient hospital services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 outpatient hospital services provided on October 25, 2021.
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 need continued care that you will be able to 
receive at a rehabilitation facility. The Plan denied your request. The Plan says the 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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with a multidisciplinary approach to daily therapy in an IRF. Our reviewer found that 
at the current level of function, your rehabilitation needs can be safely provided at a lower intensity and 
alternate setting such as in an SNF. You need routine physical therapy and and occupational therapy. Our 
physician reviewer also found that an IRF admission is not medically necessary based on medical stability, lack 
of medical complexity, and lack of rehabilitation nursing needs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have the proper indications for this procedure. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supply allowance for therapeutic continuous glucose 
monitor (cgm), includes all supplies and accessories (K0553). 
 
You asked the Plan to pre-approve the supply allowance. You say that you are currently out of this product and 
need them as soon as possible. The Plan denied your request. The Plan says the records do not support that the 
enrollee meets the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 the Plan has 
been unable to obtain records of a visit within 6 months to verify that the enrollee performs blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Supply allowance for therapeutic continuous 
glucose monitor (cgm), includes all supplies and accessories (K0553).