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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more inpatient rehabilitation to get your 
mobility back The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be met at a lower level of 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aquablation rebot procedure to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary The Plan 
denied your request. The Plan says this service is not approved. 
 
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 aquablation rebot procedure to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lorazepam medication (A9270) provided on  
November 8, 2022. 
 
You asked the Plan to pay for this medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
  
 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Lorazepam medication 
(A9270) provided on November 8, 2022.  
 
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
admission 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 record indicates the enrollee is improving but 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 they are not currently receiving but that would be available at the LTACH facility.  The elements of the coverage 
rules are not satisfied.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted special service to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve unlisted special service. You say that the services should be covered. The 
Plan denied your request. The Plan says this is available in-network. 
 
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 
unlisted special service to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
31, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to cover the service as a 
regular teeth cleaning. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the periodontal maintenance is not covered by the Plan. 
 
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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CPAP equipment to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the CPAP equipment. You say that you had a good experience with this 
provider in the past and would like to use them again. The Plan denied your request. The Plan says this 
provider is out-of-network. 
 
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 
the CPAP equipment to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve definitive drug testing of 21 drug classes. 
 
You asked the Plan to pre-approve drug testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no concern about misuse or abuse of medication nor initial drug tests showing 
an unexpected result.  
The Plan follows Medicare rules. Medicare rules state that definitive drug testing may be covered if certain 
criteria are met. 
 
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 drug testing. Our reviewer says that the 
enrollee does not meet the criteria for this testing. Our physician reviewer found the review indicates that the 
enrollee has a diagnosis of chronic pain and is maintained on chronic pain medicine. The provider must provide 
a specific reason for doing a quantitative drug testing. There is no documentation of any concern about misuse 
or abuse of medications. There are no initial drug tests that show an unexpected result. There is no specific 
clinical rationale for the testing of 21 drug classes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve definitive drug testing of 21 drug classes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements have not been met. 
 
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 Prolia. Our reviewer says that the 
enrollee did not meet the Plan's step therapy requirements. Our physician reviewer found 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 function has declined to the point that 
they can only ambulate 25 feet, consecutively, with the use of a rolling walker and requires minimal assist from 
a skilled professional to prevent falling due to deconditioning and weakness. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 7, 2023 to 
February 21, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the home health services are not supported in the medical record. Specifically, FFS home health 
services must be reported with Type of Bill 0329. The claim was billed with Type of Bill 0323. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 7, 
2023 to February 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
36 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 75 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve DME. You say that the supplies should be covered. The Plan denied your 
request. The Plan says this is available in-network. 
 
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 
durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office visits to be provided by an OON provider.  
 
You asked the Plan to pre-approve six office visits. You say that you are requesting to see a new provider at the 
same practice you previously went to. The Plan denied your request. The Plan says this provider is out-of-
network, and there are in-network providers who can provide this service and are accepting new patients. 
 
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 
six office visits to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) 
(Watchman procedure). 
 You asked the Plan to pre-approve Watchman procedure. You say that this procedure is critical. The Plan 
denied your request. The Plan says the records show the enrollee has not had a formal shared decision-making 
interaction with an independent non-interventional physician. 
 
The Plan follows Medicare rules. Medicare rules state that the Watchman procedure may be covered through 
CED if certain criteria are met. 
 
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 Watchman procedure. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found while there is 
reference to consideration of the LAAC, there is no documentation of performance of an evidence-based, 
shared decision-making interaction on anticoagulation performed by an independent, non-interventional 
physician. As such, guidelines would not support implantation of a LAAC in this 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 Watchman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous left atrial appendage closure (LAAC) (Watchman procedure).
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 requesting an expedited appeal 
of this denial based on the enrollee's condition and your strong recommendation that LTACH is the most 
appropriate level of care for this enrollee. The Plan denied your request. The Plan says criteria for admission to 
the LTACH 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 appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH would not be clinically advantageous and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure device (CPAP) 
supplies provided on February 2, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a continuous positive airway pressure device (CPAP) supplies. You say that the 
item is medically necessary. The Plan denied your request. The Plan says an authorization was not obtained 
prior to the items being rendered. 
 
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 a continuous positive airway pressure device 
(CPAP) supplies provided on February 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care and related services 
provided on December 20, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care and related services. You say that the services 
should be covered. 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 subsequent nursing 
facility care and related services provided on December 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccination services provided on November 8, 2022. 
 You asked the Plan to pay for the vaccinations. You say that the services are a covered benefit. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the vaccination services provided on November 8, 2022.