Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 17, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 physician's services provided on March 17, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, 
outpatient setting, or home health 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 that the review has determined that the complexity of the patient's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this patient 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: 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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an 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 that the enrollee is currently undergoing treatment at an ACH following surgery for a 
previously identified lung cancer. The enrollee was intubated/ventilated and subsequently received a 
tracheotomy. The enrollee is receiving ventilator weaning, supplemental feeding and rehabilitative 
therapies. There is no evidence that the enrollee requires services that are not currently available. As LTACHs 
and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to 
the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing  
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are terrified of the enrollee going 
back to the nursing home. The enrollee gets an infection every time and they are unable to care for it and the 
enrollee is taken back to the hospital. The Plan denied your request. The Plan says the medical records 
submitted do not establish that the admission into a long-term acute care facility is reasonable and 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and only requires short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 9, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 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 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 subsequent nursing facility care provided on 
March 9, 2022, by an out-of-network (OON) provider.
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 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 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You can receive further services at a lower 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 8, 2022.
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 need care around the clock as 
physical therapy and wound care is needed consistently. The Plan denied your request. The Plan says LTACH 
services are denied as not meeting criteria, however continued acute hospital stay was offered, until you can be 
discharged 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 that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81542 and 88381) provided on 
November 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that codes 81542 and 88381 are not supported in the medical record. Specifically, there is no 
documentation describing genetic testing on a sample collected on the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (81542 and 88381) provided on 
November 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided associated with an 
approved total knee replacement. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay should be covered 
because the member lives over an hour away. The Plan denied your request. The Plan says the documentation 
pre-operatively does not meet the threshold for an intensity of services or underlying hemodynamic instability 
that could only be managed in an acute inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the documentation does not support that it is reasonably expected that the 
enrollees necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided associated with an approved total knee 
replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you went to your primary care physician (PCP) and 
was told you were not ready for a refill at the drug store. You also say that you had not had your medication in 
almost two months, so you went to this provider to get your medication refilled. The Plan denied your request. 
The Plan says this provider is not a network provider with the Plan and there is no referring provider. The Plan 
also says that these services were not approved in advance. 
 
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 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 an office visit provided on June 2, 2022, by an 
out-of-network (OON) provider.
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 only way to get back to normal functioning status 
is to get the therapy from the rehabilitation center. The Plan denied your request. The Plan says needs can be 
met at a lower level of care such as an assisted living facility with home health services or part-time skilled 
services in long-term 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 that the review has determined that the complexity of the patient's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Heparin sodium. 
 
You asked the Plan to pre-approve Keytruda and Heparin sodium. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Keytruda and Heparin sodium. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Pembrolizumab 
(Keytruda) is not FDA approved for progressive metastatic non-small cell lung cancer that has progressed on 
prior treatment with this drug. In addition, no programmed cell death ligand 1 (PDL1) is given to support use as 
monotherapy. Use is not supported for off-label use my major drug compendia or the medical literature. 
Heparin is a used as a flush and standard of care. The service is not reasonable 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 Keytruda and Heparin sodium have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Keytruda and Heparin sodium.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for COVID-19 at-home test kits provided on 
January 18, 2022. 
 
You asked the Plan to reimburse you for COVID-19 at-home test kits. You say that these tests were covered. 
The Plan denied your request. The Plan says the two at-home COVID-19 tests kits were not a covered benefit 
at time of purchase. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 at-home test kits have not been met. Therefore, we decided that the Plan does not have 
to reimburse you for COVID-19 at-home test kits provided on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022 billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, 0033U, 81479, 81407, 81406, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records have been attached to 
this appeal. Please have a look at the attachment and reconsider the charges which were previously denied. The 
Plan denied your request. The Plan says does not meet the Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required.  Also, the state where the provider performs the service differs from the state where the enrollee 
resides. The provider is located in Florida, while the enrollee resides in Pennsylvania. Per the CMS guidance, 
the LCDs and LCAs should apply to the jurisdiction in which the provider is rendering the service. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022 
billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 
81335, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on May 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that you received this referral from a provider that 
is contracted with the Plan. You also say that you believe that the primary care provider (PCP) requirement has 
been satisfied. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
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 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 wound care supplies provided on May 31, 2022, 
by an out-of-network (OON) provider.