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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need skilled nursing, or skilled therapy on a daily basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs can, as a practical matter, be provided at a lower level of care. Our physician reviewer found that 
your condition does not meet Medicare criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that all physicians involved with the enrollee 
concur that LTACH is the appropriate level of care and is medically stable to be transferred to LTACH level of 
care at this time. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and does not require transfer to a 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 
 
 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 the enrollee just had surgery and needs therapy to be 
able to ambulate. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
IRF care. 
 
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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) 
(G0299) provided from May 8, 2021, to June 9, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that you would like this claim to be 
reconsidered. The Plan denied your request. The Plan says the non-contracted provider did not submit the RAP 
claim for services for dates of service May 8, 2021, to June 9, 2021, until June 9, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the skilled nursing services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided from May 8, 2021, to 
June 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Ruxience (Q5119). 
 
You asked the Plan to pre-approve Ruxience. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says that medical-necessity rules have not been met because the 
requested drug has been prescribed for an off-label and medically unaccepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ruxience. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Ruxience is not FDA-approved for your diagnosis. However, the use is supported by one of 
the major drug compendia. The documentation supports that the requested drug is safe and effective and 
otherwise reasonable and necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Ruxience (Q5119).  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided June 23, 
2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that the date-of-service should be reported as the date the specimen was 
collected. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. 
The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, June 23, 2021. Based on this information, we decided that 
Medicare rules for coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx (F1CDx) testing (0037U) provided June 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of OSAS and possible COPD. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized with 
exacerbation of HFpEF, have OSA apparently untreated, pulmonary hypertension, and severe obesity. 
Paraplegia is mentioned, but neurologic exams indicate no focal deficit. You do have spinal stenosis. There is 
no evidence for diaphragmatic weakness. There is no diagnosis of severe COPD, generalized neuromuscular 
disease, or thoracic restrictive disease, so you do not have a diagnosis for which Medicare covers a home 
ventilator. You may benefit from home BiPAP during sleep, with BiPAP titration as an outpatient to determine 
if AVAPS is 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) (0037U) testing billed for date of 
service March 9, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and was ordered 
by the enrollee's physician. The Plan denied your request. The Plan says that this claim was billed with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are three exceptions to this rule.  
 
We looked at the file and Medicare rules. The documentation provided shows that the sample in this case was 
taken for chemotherapy sensitivity testing/services performed on live tissue, and the specimen was collected 
during an outpatient biopsy procedure. It would have been medically inappropriate to have collected the sample 
outside of this procedure, and the results of this necessary testing did not guide treatment provided during the 
hospital stay. This means that an exception to the general rule has been met. The rules say that when this 
exception is met, the date of service reported must be the date the test/service was performed. The records 
show that this service was performed on March 9, 2022. Based on this information, we decided that Medicare 
rules for coverage of F1CDx testing have been met. Therefore, we decided that the Plan has to pay for 
FoundationOne CDx (F1CDx) (0037U) testing billed for date of service March 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing, on behalf of the 
enrollee, the pre-service denial of long term acute care. The Plan denied your request. The Plan says admission 
to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute hospital stay 
was offered, until the enrollee could discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with diarrhea and sepsis 
secondary to UTI, C diff infection and complicated by heart failure and atrial fibrillation. The enrollee was 
treated with antibiotics, vasopressors, fecal transplant and diuresis. The enrollee appears to be stable and 
improving and should only require short-term additional acute care services that can safely be administered at 
the current facility until more appropriate for a lower level of care soon.  
 The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy and if you go back to a skilled 
nursing facility you will not get enough attention. You say that you need the professional care. The Plan denied 
your request. The Plan says based on Medicare guidelines and the information we have about your condition 
you do not meet the requirements for 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you were admitted for lethargy. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program.  
 
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 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. You do 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 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on April 7, 2022. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says you have 
exhausted the benefit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items are not covered by Medicare or the plan. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have sufficient upper body strength to manage the wheelchair with standard controls. 
The expandable controller is not medically necessary and exceeds your 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2310, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Medicare 
guidelines for LTACH admission. The Plan denied your request. The Plan says admission to LTACH was 
denied as not meeting criteria, is not medically necessary, and can safely receive needed care in other settings, 
such as in an inpatient rehab facility or in a skilled nursing facility. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology procedures provided on September 15, 2021. 
 
You asked the Plan to pay for radiology procedures. 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for radiology procedures provided on September 15, 2021.