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

 
We decided that the Plan does not have to pre-approve proton beam treatment. 
 
You asked the Plan to pre-approve proton beam treatment. You say that the enrollee's type of cancer has an 
indication for this treatment and is suitable for coverage. The Plan denied your request. The Plan says that this 
service does not meet Medicare coverage criteria. 
 
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 proton beam treatment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that proton beam therapy is not the accepted standard, outside of exceptional 
circumstances or clinical trials.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam treatment.
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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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. 
 
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 the home health services provided from September 30, 2022, 
to October 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that the attached home health medical claim 
should be processed for payment. 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 September 30, 2022. The NOA was not received by the Plan until 
December 7, 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 the home 
health services provided from September 30, 2022, to October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electric siderails. 
 
You asked the Plan to pre-approve electric siderails. You say that you need this item to be safely loaded and 
unloaded and to get around. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve electric siderails.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate inpatient care and is currently unstable for 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 enrollee appears to be slowly improving but currently still unstable and should 
only require short-term additional acute care services that can safely be performed at the current facility until 
more stable and appropriate for a lower level of care soon. The enrollee does not require services at the 
LTACH that are not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Durolane injection. 
 
You asked the Plan to pre-approve the Durolane injection. You say that the requested injection is medically 
necessary. The Plan denied your request. The Plan says that the requested use of Durolane is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Durolane injection. Our reviewer says 
that Durolane is medically reasonable and necessary for the enrollee. Our physician reviewer found that the 
enrollee has a history of left knee pain due to osteoarthritis of the left knee. He is unable to put full weight onto 
the knee which negatively affects his activities of daily living and has had to use a walking stick for assistance. 
He has been treated with medications, physical therapy, and a corticosteroid injection, with minimal success. 
Intra-articular injections with hyaluronic acid (Durolane) are recommended as a possible option for severe 
osteoarthritis for enrollees who have not responded adequately to recommended conservative treatments to 
potentially delay total knee replacement. Intra-articular injection of hyaluronic acid can decrease symptoms of 
osteoarthritis of the knee; there are significant improvements in pain and functional outcomes with few adverse 
events. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane injection have been met. Therefore, we decided that the Plan has to 
pre-approve the Durolane injection.  
 
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 the nursing facility care provided on February 9, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are in-network with the Plan. The Plan 
denied your request. The Plan says you are not in-network, and the services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 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 the nursing facility care provided on February 9, 
2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric surgery revision. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee has terrible quality of life. 
The Plan denied your request. The Plan says the enrollee is not showing any signs of problems with the current 
bypass.  
 
The Plan follows Medicare rules. Medicare rules say that bariatric surgical management is only covered under 
certain medical indications. 
 
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 morbid obesity in the setting of previous bariatric surgery. The record does 
not indicate the presence of complications for the previous procedure. The record provided is insufficient to 
support the medical necessity of the requested procedure. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bariatric surgery revision.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 additional trips. 
 
You asked the Plan to pre-approve 100 additional trips. You say that you are requesting 100 additional rides for 
dialysis and other appointments. The Plan denied your request. The Plan says this request for 100 additional 
trips is not covered by your health plan.  
 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 a maximum of up to 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that as of June 28, 2023, 
you have used 32 trips, had 40 trips remaining, and you will have exceeded your benefit limit. Based on this 
information, we decided that you have, or will have, exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve 100 additional trips.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for 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 enrollee appears to be currently unstable and should only require short-term 
additional acute care services that can safely be performed at the current facility until more appropriate for a 
lower level of care soon. The enrollee does not require services at the LTACH that are not already available at 
the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: 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 services are medically necessary for you to return 
to your baseline. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternative setting.  
 
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 you do 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90834 billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 90834. You say that these services had different providers. The 
Plan denied your request. The Plan says payment for code 90834 is bundled into payment for code 90853. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 90834 
is a column II code to column I code 90853. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 90834 billed for date of service October 24, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with an outpatient POS code. However, the records show that the enrollee was an inpatient when the lab services were provided. As such, an 
inpatient POS code should be used in this case. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on December 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve Venofer. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Intravenous Iron Therapy is covered for iron 
deficiency anemia for patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin 
therapy. 
 
We looked at the file and Medicare rules. The records do not show that the patient is undergoing chronic 
hemodialysis. Based on this information, we decided that Medicare rules for coverage of Venofer have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Venofer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 23, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that this should be fully 
covered since it was an emergency. 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 $120 
copayment for emergency care.  
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on January 23, 2023.
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 services are medically necessary, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room visit provided on 
October 13, 2022, to November 17, 2022. 
 
You asked the Plan to waive the copayment for each emergency room visit. You say that all of these services 
were for emergencies and should be fully covered. 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 $120 
copayment for emergency care.  
You have been asked to pay a $120 copayment for each emergency room visit. This item/service falls within 
the emergency care 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. The records show you have only been asked to pay a $100 copayment on October 13, 2022. 
Therefore, we decided that the Plan does not have to waive the copayment for each emergency room visit 
provided on October 13, 2022, to November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene panel (81455) provided December 21, 
2022.  
 
You asked the Plan to pay for the genetic testing. You say that the doctor regarded the test as a medically 
necessary and valuable tool when determining treatment for the enrollee. The Plan denied your request. The 
Plan says the requested test is not reasonable and necessary because Tempus xF is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion 
in vitro diagnostic or an FDA approved or cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus Gene panel (81455) provided December 21, 
2022.