Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires SNF care. The Plan 
denied your request. The Plan says daily skilled services are not required. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was 
admitted to the hospital after a fall at home. He hit his head on the floor but did not suffer a significant injury. 
The most recent therapy documentation indicates the member is able to ambulate at least household distances 
with a walker and minimal assistance. He is able to transfer without hands on assistance. 
 
The member has stabilized medically and is ready for discharge from the hospital. The member does not 
require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive 
further rehab services at a lower level of care. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care. 
 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 physician reviewer 
found the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not 
meet 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: 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs, was monitored for tremors and your lungs were clear. You were at contact guard assist level for 
functional mobility including gait to 400 feet. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this ventilator is to be used for the 
treatment of obstructive sleep apnea syndrome (OSAS). The Plan denied your request. The Plan says the 
request for a home mechanical ventilator to treat OSAS that is not covered for this diagnosis. 
 
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 the home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  You have severe obstructive sleep apnea. You do 
not have chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. 
Medicare does not cover a home ventilator for this diagnosis. You are having difficulty tolerating bilevel 
positive airway pressure (BiPAP), which is the appropriate treatment. The medical notes do not describe the 
nature of the intolerance. There has been no attempt to address the intolerance, other than switch to a ventilator. 
The denial is upheld.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network services. You say that the Plan's facilities are too far. The 
Plan denied your request. The Plan says there are in-network providers available to provide medically 
necessary care. 
 
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. The record indicates that the requested 
provider is not accepting patients with your Plan. 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 an office visit 
and services to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied 
your request. The Plan says you do not meet Step Therapy criteria for coverage of Feraheme. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found the requested medication is a new 
start.  The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from the plan's preferred step one alternative.  The elements of the coverage criteria 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography and nerve conduction studies 
provided to the enrollee on May 11, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
 CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report does not include 
documentation of electromyography (EMG), each extremity or nerve conduction studies. The documentation 
does not confirm that these procedures were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography and nerve conduction studies provided to the enrollee on  
May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare criteria for coverage of Retacrit. 
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically necessary. Our physician reviewer found use of this drug requires that the member's 
iron status has been evaluated and sufficient iron levels will be maintained prior to initiation of therapy and 
continuation of therapy. The review has determined that the documentation does not support that Retacrit is 
medically reasonable and necessary for the patient. The documentation does not support that the Retacrit is safe 
and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Foundation one liquid biopsy (0239U) provided to the enrollee on 
November 22, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that there is a lack of documentation of adequate tissue, and this test is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the results of the extensive studies demonstrate that FoundationOne Liquid CDx accurately and 
reproducibly detects the major types of genomic alterations as well as complex biomarkers, such as MSI, 
bTMB, and tumor fraction. The data described here support the validity and utility of using a well-validated 
cfDNA-based CGP assay in the therapeutic management of cancer patients. The comprehensive nature of the 
described performance evaluation studies demonstrates the reliability of test results which can provide confidence to physicians in the use of this assay to provide genomic profiling results for their patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the Foundation one liquid biopsy (0239U) provided to the enrollee on November 22, 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: 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
daily complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive 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 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 waive the copayment for the laboratory services provided on May 5, 
2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you would like 
reconsideration because you were told you would not be responsible for more than the $10 copayment. The 
Plan denied your request. The Plan says this copayment 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 $10 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Diagnostic Tests 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 the laboratory services provided on May 5, 2021. If you believe you are being balance billed, please contact the 
Plan directly.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 20, 2021, to 
June 17, 2021. 
 
You asked the Plan to pay for the home health services. You say that you feel that it is not appropriate for the 
Plan to apply this Medicare 5-day RAP filing window as the Plan did not make this announcement in its 
policies. You also feel that this time frame is not appropriate since the Plan does not have access to Medicare's 
database for OASIS data. The Plan denied your request. The Plan says the Medicare rules for home health are 
followed by the Plan. Since this RAP was not submitted until more than 30 days after the From date, no 
payment can be made. 
 The Plan must follow Medicare rules. Medicare rules say that RAP submissions must be accepted within 5-
days of the From date of the HH episode of care. Payment on the final claim is reduced by 1/30th for every day 
beyond the limit the RAP is not submitted. 
 
In this case, the RAP was not submitted until more than 30 days after the limit. As such, no payment can be 
made. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
May 20, 2021, to June 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on June 21, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the records support that this was a 
medically necessary procedure. The Plan denied your request. The Plan says there is no documentation of a 
consult with the primary/attending physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on June 21, 2021.