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

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary 
osteoarthritis of the right knee. The exam reveals mild tenderness of the medial joint line. She has significant 
tenderness on the medial and patellar facets with severe crepitus of the patellofemoral joints. She has an 
antalgic gait. X-rays are noted to show tricompartmental osteoarthritis, greatest at the patellofemoral joint 
where there is bone-on-bone; subchondral sclerosis is present. There is no documentation of a trial and failure 
of recent reasonable and comprehensive less-invasive conservative care measures. The TKA Is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee arthroplasty (TKA).
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 this is 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 that the clinical documentation shows that the enrollee has functional impairments, 
and notes that the evaluating therapist recommends intense therapy. However, there is no documentation to show that you would require close medical monitoring on an inpatient basis by a physiatrist or any active 
comorbidities. Deep vein thrombosis is not an IRF compliant diagnosis. 
 
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 a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has recurrent congestive 
heart failure. Although the CardioMEMs device as approved by the Food and Drug Administration (FDA) in 
2014, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 24, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are an independent laboratory, and you 
receive the specimen and test requests from an ordering facility and perform the test in your lab. The Plan 
denied your request. The Plan says they cannot determine how the enrollee came to the servicing provider, 
or whether the services are medically necessary. 
 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. 
Specifically, there is no referral/authorization on file, no medical records or clinical information. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on August 24, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation treatment (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found with whole brain radiation (including prophylactic brain radiation), it is not standard to use 
IGRT (and no plausible rationale for the need of IGRT was offered in the case records). Prophylactic brain 
radiation therapy is medically necessary for small cell lung cancer. However, there is not a plausible or 
rationalized need for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation treatment (IGRT).
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 you have been in the hospital for ten days, and the 
doctor requested for you to be put in an SNF. The Plan denied your request. The Plan says this does not meet 
Medicare criteria. The Plan also says that the enrollee can receive ongoing therapy at home with home health 
care or on an outpatient 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. Our 
physician reviewer found there are no identifiable skilled therapy service needs. Our physician reviewer also 
found that you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided May 23, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this test is medically necessary. The Plan denied 
your request. The Plan says this test is not covered because it is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided May 23, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Positron Emission Tomography (PET) and Computed 
Tomography (CT) scan from head 
to thigh for the enrollee. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that there is a concern related to the cells in your 
body that are not normal. The Plan denied your request. The Plan says this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 the PET/CT scan. Our reviewer says 
that the requested scan is not medically reasonable or necessary. Our physician reviewer found that the 
provided medical records are quite confusing. There is an encounter on August 11, 2022 describing no 
progression in the left upper lobe lesion the prior CT, but there are plans to order another CT as the most recent 
one was at an outside facility. There is no report of this planned repeat CT in the records. There is a note in the 
encounter from 8/29/22 that there has been an increase in size of the left upper lobe mass. However, without a direct radiology report of this finding, the requested PET/CT scan cannot be considered medically reasonable 
or necessary. This has been requested for unclear reasons. A letter apparently describes pharyngeal cancer 
recently diagnosed which is not supported by the enclosed records. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Positron Emission Tomography (PET) and Computed Tomography (CT) scan from 
head 
to thigh for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation of the left shoulder. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because Vvscosupplementation of joints other 
than the knee(s) are considered not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation is only covered for the 
knee.  
 
As the request is for the shoulder it cannot be approved. Based on this information, we decided that Medicare 
rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-
approve viscosupplementation of the left shoulder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selectMDx liquid biopsy provided on November 30, 
2021. 
 
You asked the Plan to pay for the selectMDx liquid biopsy. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The selectMDx liquid biopsy at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the selectMDx liquid biopsy provided on November 30, 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 is stable and ready to 
transition to a lower level of care. You say the enrollee is too complex for a skilled nursing facility. The Plan 
denied your request. The Plan says the criteria for LTACH services have 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 is still critically ill and requires acute critical care services. 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. 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 3, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible 
to pay this. The Plan denied your request. The Plan says the cost share has been applied 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 $250 
copayment for each non-Medicare covered ambulance stabilization when there is no transport.  
 
 
 
 
 
 
 You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
Ambulance Services 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 ambulance services 
provided on June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for an approved shoulder 
replacement procedure. 
 
You asked the Plan to pre-approve the requested inpatient admission. You say that it is felt that inpatient 
admission is appropriate. The Plan denied your request. The Plan says the enrollee can be admitted for an 
outpatient procedure and converted to inpatient if needed due to complications. 
 
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 pre-approve the requested inpatient admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this 
case. Our physician reviewer found the documentation reveals that the 76-year-old enrollee was diagnosed with 
glenohumeral joint arthritis and a complete rotator cuff tear. There is severe pain which interferes with 
function. He is undergoing a planned total shoulder arthroplasty. The enrollee is medically stable and has been 
provided medical clearance to undergo this elective procedure. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. 
 
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 requested inpatient admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient admission for an approved shoulder replacement procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided January 1, 2020 to January 4, 
2020. 
 
You asked the Plan to pay for the inpatient services. You say that DRG 308 was correctly billed. The Plan 
denied your request. The Plan says documentation does not support DRG 308.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 308. 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 inpatient services. Our reviewer says that the records do not support the DRG 
billed. Our physician reviewer found clinical evidence did not support assignment of the condition, The review 
has determined that the appropriate DRG for the admission was DRG 309.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided January 1, 2020 to January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43235 billed for date of service November 8, 
2021. 
 
You asked the Plan to pay for procedure code 43235. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 43235 is bundled into payment for code 43239.  
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, we have confirmed that code 43235 
is a column II code to column I code 43239. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 43235 billed for date of service November 8, 
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. The Plan denied your request. The Plan says the 
enrollee's medical needs can be met in the current setting. 
 
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 still requires acute care services before transitioning to a lower level of 
care. 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 she is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied.  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 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.