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 you are requesting IRF versus a lower level of care, 
as the enrollee has rehabilitation goals that include returning to her prior level of function. You also say the 
goal is to be independent with all mobility and activities of daily living, and able to live alone with services. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information they have about 
the enrollee; the enrollee does not meet the requirements. The Plan also says that the enrollee could receive 
care in another setting. 
 
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 member does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician 
reviewer also found that while the medical record supports a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Our physician reviewer also found that 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to move on your own. You also say 
that if you do not have continuous care, you could worsen since you are unable to move on your own. You also 
say that the recovery is slow and painful, and will be quicker with the rehabilitation. The Plan denied your 
request. The Plan says that Based on Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services 
being requested 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found a traumatic brain injury (TBI) and/or TBI with multiple traumas is an IRF compliant diagnosis. Our 
physician reviewer also says that clinical documentation shows that the member would be expected to continue 
to require close medical monitoring on an inpatient basis. Our physician reviewer also says that evaluating 
therapists document that the patient would tolerate and benefit from multi-disciplinary and intense 
rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of the Watchman device (33340) provided 
January 6, 2022. 
 
You asked the Plan to pay for the Watchman procedure. You say that please have the attached requested 
medical records reviewed for payment reconsideration. The Plan denied your request. The Plan says the records 
do not meet the criteria guidelines as the records did not include reason for inability to take long term oral 
anticoagulation. 
 
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 Watchman procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support any apparent contraindication to anticoagulation. 
As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement 
would not be considered reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Watchman procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for the placement of the Watchman device (33340) provided January 6, 2022.
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 that this member is stable and suitable 
for transfer to an LTACH facility. You also say that the member cannot be adequately cared for in his current 
condition at a Skilled Nursing facility or any other lower level of care. The Plan denied your request. The Plan 
says admission to LTACH was denied as not meeting criteria and not medically necessary. The Plan also says 
that continued acute hospital stay was offered, until the member 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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 a more intensive rehabilitation. The 
Plan denied your request. The Plan says the criteria for IRF coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. 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 
you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx testing provided June 7, 2021. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that this service 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. 
 
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, June 7, 2021. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne Liquid CDx testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne Liquid CDx testing provided June 7, 2021.  
 
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 pre-approve consultation and office visits to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve consultation and office visits. You say that the enrollee needs to see an 
oncologist and the enrollee would like to see this provider. The Plan denied your request. The Plan says the 
requested services can be provided to the enrollee from 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 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 
consultation and office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 30, 2022 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or 
delusions. He was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stabilization of lower spine bone (CPT code 22511). 
 You asked the Plan to pre-approve the surgical services. You say that your health is in danger. The Plan denied 
your request. The Plan says your request is medically necessary because your records show you do not have an 
acute, osteoporotic vertebral compression fracture between T1 and L5. 
 
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 surgical services. Our physician 
reviewer found your fracture is outside of the accepted levels for this procedure. Therefore, the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stabilization of lower spine bone (CPT code 22511).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that these services only cost $30 
previously. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $165 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
 
 
 
 
 You have been asked to pay a $165 copayment for the wound care. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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. Please note that 
the claim was billed with a hospital location for the wound care. Therefore, we decided that the Plan does not 
have to waive the copayment for the wound care provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on July 26, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is not covered when a 
treating clinician is not considering treatment with a medication that has an actionable drug-gene interaction, or 
when the use of a medication with a drug-gene interaction is not reasonable and necessary. 
 
We looked at the file and Medicare rules. The documentation does not support that medications are being 
considered for use (or already being administered) that are medically necessary, appropriate, and approved for 
use in the patient's condition and are known to have a gene-drug interaction. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for genetic testing (81479) provided on July 26, 2021.
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 would benefit from LTACH 
services. The Plan denied your request. The Plan says the criteria for LTACH coverage 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 the enrollee appears to be somewhat still unstable but improving and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time. 
 
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: 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 are appealing with supporting records. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
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 clinical documentation shows that the patient does have functional impairments and 
active comorbidities, but primary team recommends skilled nursing facility (SNF) services. Our physician 
reviewer also found that there is nothing to show that the patient would tolerate intense therapy, thus IRF 
criteria has not been met or 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that this was just a phonecall, you do 
not understand why the charge is so high. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 a $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for telehealth visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 waive the copayment for telehealth visit provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) and presumptive drug 
testing (80307) provided September 13, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you are sending supporting medical records to 
prove the necessity of the services. The Plan denied your request. The Plan says missing patient medical 
records 
 
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 drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there was insufficient information submitted. The review indicates that the 
items/services at issue in this case were not medically reasonable or 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing (G0483) and presumptive drug testing (80307) provided September 
13, 2021.