Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show complex rehabilitation and 
medical needs which require a physiatrist.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter COVID-19 test kits provided on June 
26, 2023. 
 
You asked the Plan to reimburse for over-the-counter COVID-19 test kits. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says over the counter (OTC) COVID-19 tests are 
not covered by Medicare after May 11, 2023.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to reimburse for over-the-counter 
COVID-19 test kits provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 months. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator for 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee has not tried nor 
failed bilevel positive airway pressure (BIPAP) with or without average volume-assured pressure support 
(AVAPS) therapy. She would and may benefit from BIPAP but that is to be determined by the provider. At this 
time, there is insufficient documentation or data to support a home ventilator. Hence, a home ventilator is not 
best practice nor is it standard 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 a ventilator for 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyramza, Taxotere and Ondansetron. 
 
You asked the Plan to pre-approve Cyramza, Taxotere and Ondansetron. 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 may pay for unlabeled uses for anti-cancer 
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 Cyramza, Taxotere and Ondansetron. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review 
indicates that the enrollee has metastasis to the left femur and pleura. The positron emission tomography (PET) scan after 4 cycles of Cyramza and Taxotere demonstates disease progression. The requested use of Cyramza, 
Taxotere and ondansetron is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
Continuation of the regimen with documented disease progression is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cyramza, Taxotere and Ondansetron have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Cyramza, Taxotere and Ondansetron.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on June 22, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the critical care needs of the enrollee. The Plan denied your request. The Plan says that the enrollee does not 
meet the criteria for 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has multiple active medical conditions that will likely require hospital management 
meeting or exceeding 25 additional days. The enrollee is currently receiving intravenous anti-fungal medication 
for their foot wound, as well as intravenous furosemide to manage their heart failure with fluid overload. The 
complexity of managing the enrollee's wound care, heart failure and diabetes in the context of their morbid 
obesity indicates that LTACH is the most appropriate medical setting for their continued 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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate-
specific membrane antigen (PSMA) positron emission tomography 
(PET) scan. 
 
You asked the Plan to pre-approve a PSMA PET scan. 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. Medicare rules say that PET 
scans are covered under certain conditions. 
 
We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of a 
PSMA PET scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a prostate-specific 
membrane antigen (PSMA) positron emission tomography (PET) 
scan.
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 needs this level of care. The Plan denied 
your request. The Plan says the enrollees medical condition does not require IRF services.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter COVID-19 test kits provided on June 
26, 2023. 
 
You asked the Plan to reimburse for over-the-counter COVID-19 test kits. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says over the counter (OTC) COVID-19 tests are 
not covered by Medicare after May 11, 2023.  
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to reimburse for over-the-counter 
COVID-19 test kits provided on June 26, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy services provided on 
August 2, 2023. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you should not be charge 
for a finger split. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for x-ray services and a $40 copayment for occupational therapy for outpatient hospital services and 
outpatient rehabilitation services.  
  
You have been asked to pay a $20 copayment for x-ray services and a $40 copayment for occupational therapy 
for occupational therapy. This item/service falls within the outpatient hospital services and outpatient 
rehabilitation 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 
occupational therapy services provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,500 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $2,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network venous duplex scan and 
biopsy procedure provided on July 14, 2023, and August 1, 2023. 
 
You asked the Plan to waive the copayment for a duplex scan and a biopsy. You say that you cannot afford 
these copayments. The charges are too high and will cause you a financial hardship. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for procedures at any other location, and a $310 copayment for outpatient surgery services.  
 You have been asked to pay a $435 combined copayment for a duplex scan and a biopsy. This item/service 
falls within the procedures at any other location, and outpatient surgery 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 an in-network venous duplex scan and biopsy procedure provided on 
July 14, 2023, and August 1, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not competent enough to be released 
home and would benefit from a SNF admission. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for a SNF level of care admission.   
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on July 27, 2023. 
 
You asked the Plan to pay for a telehealth visit. You say that this patient is homebound and cannot come to the 
office. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth visit 
provided on July 27, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Oncotype Dx Breast genetic testing provided on June 20, 2023. 
 
You asked the Plan to pay for the Oncotype Dx Breast genetic testing. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the services at issue were 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Oncotype DX Breast genetic testing is covered 
when medically necessary for patients with estrogen-receptor positive, node-negative carcinoma of the breast 
findings. 
 
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 Oncotype Dx Breast genetic testing. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has T1bN0 invasive ductal carcinoma after a left lumpectomy and 
sentinel node biopsy (0 out of 2 lymph nodes positive for cancer).  The enrollee has estrogen receptor positive 
(ER+), progesterone receptor positive (PR+), and human epidermal growth factor receptor 2 negative (HER2-) 
carcinoma of the breast. This means that the Oncotype DX Breast genetic testing in dispute was medically 
reasonable and appropriate for the enrollee with findings of estrogen-receptor positive, node-negative 
carcinoma of the breast. 
 
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 Oncotype Dx Breast genetic testing have been met. Therefore, we decided 
that the Plan has to pay for Oncotype Dx Breast genetic testing provided on June 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the rhinoplasty provided on November 11, 2022. 
 
You asked the Plan to pay for the rhinoplasty. You say that you want the Plan to reconsider payment. You say 
you should be reimbursed for the full amount of the services billed by the provider. The Plan denied your 
request. The Plan says that the claim processed correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the rhinoplasty by a contract provider. The file does not show that the Plan provided 
notice that the rhinoplasty would not be covered. The record shows that the provider originally did not think 
this service would be covered and the provider must return the additional amount to you. Under Medicare rules, 
this means the rhinoplasty is considered approved by the Plan. Therefore, we decided that the Plan has to pay 
for the rhinoplasty provided on November 11, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's health and recovery will be adversely 
affected if required to wait standard time frame and the IRF care is further delayed. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility.  
 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a lower level 
of care (ex. 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 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.