Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation with an oncologist to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a consultation. You say that you need more information regarding the 
enrollee's condition. The Plan has already dragged out the enrollee's care. The Plan denied your request. The 
Plan says the enrollee must receive care from network providers. Care is available within the Plan. 
 
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 
a second opinion consultation with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent and active prior to coming to 
the hospital and you wish to return to being independent as quickly as possible. You say admission to an IRF 
will allow you to participate in the required 3 hours of therapy and that you will not get that in a lower level 
setting. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the device could prevent another 
hospitalization. The Plan denied your request. The Plan says the device would not improve the outcome of the 
enrollee's condition.  
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. Studies remain encouraging and suggest 
an improvement in heart failure symptoms with the use of the device. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. The Plan denied your request. The Plan says a CT 
scan of the thorax is not medically necessary.  
 
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 of the thorax. Our reviewer 
says that the CT scan of the thorax is not medically necessary. Our physician reviewer found that the enrollee 
has a undiagnosed pancreatic tail mass that has been stable since 2016. The CT scan was ordered to evaluate 
new onset abdominal pain, however without a diagnosis and a biopsy there is an unclear indication for a CT 
scan of the chest. 
 
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 of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0261) and an immersion 
therapy mattress (E1399) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a semi electric hospital bed and mattress. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee must use network 
providers to receive medical services. 
 
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 
a semi electric hospital bed (E0261) and an immersion therapy mattress (E1399) to be provided by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 14, 2022, 
to July 18, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly. The Plan denied your request. The Plan says the secondary diagnosis code N17.9 is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, N17.9, defined as acute 
kidney failure. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the secondary diagnosis code is not supported. 
Our physician reviewer found that it was documented that the enrollee likely had prerenal azotemia. The 
documentation did not show evidence of a 0.3 ml/kg/dL rise in 24 hours, oliguria, anuria, or three times 
baseline rise in creatinine levels to meet the definition of acute kidney failure. The documentation, therefore, 
does not sufficiently support the secondary diagnosis N17.9 (acute kidney failure).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from July 14, 2022, to July 18, 2022, at the DRG originally billed.
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 the enrollee's best chance for a quicker 
recovery and more favorable outcome will be with an admission to an LTACH. The Plan denied your request. 
The Plan says an LTACH admission 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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that the enrollee needs NIV due to respiratory failure.  
The Plan denied your request. The Plan says there has not been a failure of a lower level respiratory assist 
device.  
 
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 NIV. Our reviewer says that the requested NIV is not shown to be medically reasonable and necessary at this time.  Our physician reviewer 
found the enrollee suffers from chronic respiratory failure with COPD and obstructive sleep apnea. This does 
support the need for respiratory support; however, there is no documented failure of bilevel positive airway 
pressure (BiPAP) with or without average volume-assured pressure support (AVAPS). An NIV would not be 
appropriate unless BiPAP has failed.  
 
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 NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy x2 and occupational therapy 
x1 visits. 
 
You asked the Plan to pre-approve home health services. You say that the request is not medically necessary 
because the records do not show the enrollee needs further skilled home health therapy services. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
provider plan of care in the available documentation, thus the records do not show that skilled therapy services 
(2 home health PT sessions and 1 home health OT session) would be required in the home setting to effectively 
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/ 
perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy x2 and occupational therapy x1 visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy. 
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you are 
functioning at a high level and could continue to improve with repetitive exercise. The unique skills of a 
therapist are not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuropsychological testing evaluation (96132) and a 
psychological or neuropsychological test administration and scoring by technician, two or more tests, any 
method; first 30 minutes (96138). 
 
You asked the Plan to pre-approve a neuropsychological testing evaluation. You say that you would like the 
Plan to provide coverage for neuropsychological testing evaluation with a pain management specialist. The 
Plan denied your request. The Plan says the requested provider is not credentialed to provide the requested 
neuro-psychological testing.  
 
The Plan must follow Medicare rules. Medicare rules say that psychological testing requires a clinically trained 
examiner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuropsychological testing evaluation have not been met. Specifically, all psychological tests 
should be administered, scored, and interpreted by a trained professional such as a clinical  
psychologist, psychologist, advanced nurse practitioner with education in this area, or a physician assistant who 
works with a psychiatrist with expertise in the appropriate area. Therefore, we decided that the Plan does not 
have to pre-approve a neuropsychological testing evaluation (96132) and a psychological or 
neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 
minutes (96138).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve PBRT. 
 
You asked the Plan to pre-approve PBRT. You say that this therapy is recommended to reduce immediate and 
late toxicities. The Plan denied your request. The Plan says that this is not standard medical treatment for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the American Society for Radiation Oncology recommendations and considering 
the unique situation of the enrollee, proton therapy is medically necessary in case of re-irradiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have been met. Therefore, we decided that the Plan has to pre-approve 
PBRT.  
 
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 Envisia Genomic Classifier test (81554) provided on March 19, 
2023. 
 
You asked the Plan to pay for the Envisia Genomic Classifier test. You say that the Envisia Genomic Classifier 
test is a covered service under the Medicare program for patients with idiopathic pulmonary fibrosis. The Plan 
denied your request. The Plan says that this testing does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that the Envisia test is covered when the criteria listed in 
the Medicare rules section 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 pay for the Envisia Genomic Classifier test. Our 
reviewer says that this test was medically necessary. Our physician reviewer found that the enrollee has 
nodules on the CT scan and underwent a bronchoscopy for diagnosis of this lesions. The genetic testing of the 
sample is appropriate for evaluation of other causes of lung disease and is appropriate in this situation. 
 
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 Envisia Genomic Classifier test have been met. Therefore, we decided that 
the Plan has to pay for the Envisia Genomic Classifier test (81554) provided on March 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Delivery Meals including preparation per meal. 
 
You asked the Plan to pre-approve Home Delivery Meals including preparation per meal. You say that even 
though her primary diagnosis was abdominal pain, she was actually being seen for heart failure. The Plan 
denied your request. The Plan says that although the member does have a history of Congestive Heart Failure, 
the principal diagnosis at time of discharge on June 24, 2023, was abdominal pain, which does not meet the 
Plan's benefit coverage criteria. 
 
The Plan contract covers Home-delivered meals. The Plan says the Plan covers meals delivered to your home 
immediately following discharge from a network hospital as an inpatient due to congestive heart failure, up to 
two meals per day in a consecutive four-week period, once per calendar year. 
 
We looked at the file and the Plans rules. The file shows that the primary diagnosis was abdominal pain. Based 
on this information, we decided that Plans rules for coverage of Home Delivery Meals including preparation 
per meal have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Delivery 
Meals including preparation per meal.
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 needs assistance from the nursing staff. 
The Plan denied your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 based on the medical records provided there is no documentation that daily 
skilled services are required. The records document that the enrollee is very limited functionally but does not 
show that the enrollees mobility status and cognitive status as such that daily inpatient skilled therapy services 
are necessary. There is no documentation that the enrollee requires the services on an inpatient basis, only in a 
skilled nursing facility setting. The records support that services in a long-term care facility on a part time basis 
(3-4 times per week) are appropriate in this case. 
 
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.