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 enrollee has multiple acute medical 
needs and the safest discharge plan at this time is an LTACH. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that 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 requested service cannot be 
recommended as 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 8, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility must be enrolled to participate in the 
Medicare program.  
 The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 8, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan. You say that you are in pain, and you need the CT scan urgently.  
The Plan denied your request. The Plan says that you do not meet the medical necessity criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the request for a CT scan of the abdomen and 
pelvis is reasonable to assess the size of the ventral hernia and to estimate the amount of fat and bowel within 
the hernia. A CT scan should be approved prior to the development of any clinical sign of entrapment or 
strangulation. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on January 18, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for molecular diagnostic tests, such as the test at 
issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEX Diagnostics Exchanges shows that this testing is 
listed as covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
provided on January 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on December 15, 2022. 
 
You asked the Plan to pay for the telehealth services. The Plan denied your request. The Plan says no benefit 
coverage is available for virtual services performed by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for telehealth services provided on December 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 30, 2022 to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 30, 2022 to 
February 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 7, 2022 to 
February 4, 2022. 
 You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 7, 2022. The NOA was not received by the Plan until February 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on January 7, 2022 to February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH level of care is required to 
manage all of your medical issues. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary to monitor the enrollee 
for lymphedema. The Plan denied your request. The Plan says there is little evidence in medical literature to 
suggest that this is an appropriate test. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that bioimpedance spectroscopy is medically reasonable and 
necessary for the enrollee in this case, as the case file does not contain documentation that this enrollee has a 
diagnosis of lymphedema.  
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve bioimpedance spectroscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in dire need of a ventilator 
and cannot go do a sleep study to get a bilevel positive airway pressure (BiPap) because the hospital does not 
do sleep studies at home. The Plan denied your request. The Plan says based on Medicare guidelines, the 
noninvasive ventilator requested does not meet the requirements for approval.  
 
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 a home ventilator. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found that in this case, the record indicates 
that the enrollee has acute on chronic hypoxic and hypercapnic respiratory failure in the setting of chronic 
obstructive pulmonary disease. The record indicates that the enrollee was successfully treated with BiPAP 
while in the hospital. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with average volume-assured pressure support (AVAPS) capability and failure of such a device has 
not been documented. The Plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve the PVA procedure. You say that the enrollee's recent fall worsened her 
prior compression fractures, and this procedure would be helpful. The Plan denied your request. The Plan says 
the criteria for the requested treatment are not met.  
 
The Plan follows Medicare rules. Medicare rules say that PVA for the treatment of compression fractures is 
covered when the fractures are either acute or subacute as evidenced by advanced imaging.  
 
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 PVA procedure. Our reviewer says 
that the criteria for the requested PVA procedure are not met.  Our physician reviewer found there is no 
advanced imaging showing that the fractures are acute or subacute.  
 
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 PVA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Remicade, Infliximab, Inflectra, or 
Simponi Aria first. 
 
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 Rituxan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Remicade, Infliximab, Inflectra, or Simponi Aria first before they will approve the requested drug. In this case, 
the enrollee has not tried and failed a required drug. There is no documentation provided indicating that the 
Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 5, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that a CT scan is needed. The Plan denied your request. 
The Plan says no documentation was submitted showing the medical necessity for a CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that a CT 
scan is not medically necessary. Our physician reviewer found the medical necessity of the requested CT of the 
neck has not been established in the limited submitted material. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
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 there is not another safe discharge plan as they have 
a deceased upper and lower extremity range. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met in other settings.  
 
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 enrollees 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 pay for the office visit and nail debridement provided on August 29, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you advised the facility staff to obtain prior 
authorization. You say that the enrollee was called in before authorization was obtained. You also say that you 
had assumed authorization had been obtained as you requested. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
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. 
 
You are not a network provider with the Plan. 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 the office visit and nail debridement provided on August 29, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on November 3, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on November 3, 2022.