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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an inpatient 
rehabilitation faculty. 
 
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 is medically stable and does not need physician supervision at least 3 
times per week. The enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day 
at least 5 days per week as the enrollee would not likely tolerate this level of therapy. The complexity of the 
enrollee's nursing, rehab, and medical, needs (combined complexity) does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88329) provided on October 5, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were referred by the enrollee's 
treating physician and were necessary. 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, for a patient who is registered inpatient or 
outpatient of a hospital, the correct POS code is that of the same inpatient or outpatient hospital setting, 
regardless of where the face-to-face service occurs. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathology services have not been met. Specifically, this claim was billed with an outpatient POS 
code (22). However, the records indicate that the enrollee was registered inpatient status on the date in 
question. Therefore, we decided that the Plan does not have to pay for pathology services (88329) provided on 
October 5, 2022.
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 the enrollee. 
The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as, a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the Healthy Food Allowance. 
 
You asked the Plan to pre-approve the Healthy Food Allowance. You say that you have congenital dementia, 
cardiovascular disease, high blood pressure, and have been taking medicine for many years. You also say that 
the prescription medicine given to you can prove that you have the above diseases, and you can apply for the 
benefit of $25 a month for the member benefit to buy food, and you hope to be approved. The Plan denied your 
request. The Plan says that your Primary Care Provider (PCP) reported that you do not have any qualifying 
medical conditions that makes you eligible for the healthy food supplemental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support that the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the Healthy Food Allowance. The qualifying 
diagnoses listed in the Evidence of Coverage are vague, and no medical records were provided for this case. It 
is the burden of the Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated. Therefore, we decided that the Plan has to pre-approve the Healthy Food Allowance.  
 
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 office visit and mobile x-ray services rendered on 
November 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an 
office setting; however, the file shows that the services were performed in a skilled nursing facility. Therefore, 
we decided that the Plan does not have to pay for the office visit and mobile x-ray services rendered on 
November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral blepharoplasty. 
 
You asked the Plan to pre-approve a bilateral blepharoplasty. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that blepharoplasty services are covered for 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 a bilateral blepharoplasty. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the Marginal Reflex 
Distance is 4.5 millimeters(mm) in the right eye and 4.0mm in the left eye, which is not considered to be 
visually significant (not less than 2.0mm).  The measurements and photos provided do not correlate with the 
visual field results. 
 
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 bilateral blepharoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral blepharoplasty.
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 bilevel positive airway pressure (BIPAP) is 
not meeting the enrollee's respiratory demands. You say the enrollee has chronic obstructive lung disease. You 
also say that the requested ventilator is medically necessary for the enrollee. The Plan denied your request. The 
Plan says the requested ventilator is not medically necessary. 
 
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 the requested home ventilator is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has obstructive sleep apnea in the setting of morbid obesity without documentation 
of restrictive lung disease. The reviewer found that the 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 bilevel positive airway pressure (BiPAP) machine with average volume-assured 
pressure support (AVAPS) capability and failure of such a device has not been documented. Therefore, the 
reviewer found that the requested home ventilator is not medically reasonable or necessary 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 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: 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 appealing with supporting 
records. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 does not require services at the LTACH that are not available in the 
current acute care hospital setting. All medically necessary care is being provided in the current 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator from an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you want the concentrator from this brand. The 
Plan denied your request. The Plan says the services are available from network providers. 
 
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 portable oxygen concentrator from an out-of-network (OON) provider.
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 inpatient rehabilitation is necessary to regain 
strength and mobility, you are 93 years old, recovering from extensive thoracic procedure and have been in 
hospital for 19 days, mostly in bed. The Plan denied your request. The Plan says your records do not show that 
you need an intensive team for your care, services needed can be provided safely in other settings, at a skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tempus xG Breast panel. 
 
You asked the Plan to pre-approve these services. You say that you have an extensive family history of cancer. 
The Plan denied your request. The Plan says screening tests are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a Tempus xG Breast panel, is being requested solely for screening purposes. 
The file shows that you do not have a personal history of cancer. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pre-approve a Tempus xG Breast 
panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit provided on 
December 30, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. You say that the services were 
rendered in good faith. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 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 a domiciliary, rest home, or custodial care visit provided on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided from April 2, 
2022, through April 4, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that the documentation supports the 
evaluation and management level of care billed. The Plan denied your request. The Plan says the medical 
records do not support a detailed interval history and medical decision making of high complexity. 
 
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, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder 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 subsequent hospital care (99233). Our reviewer says that the 
documentation does not support procedure code 99233. Our reviewer found there was no detailed interval 
history or decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care (99233) have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital care (99233) provided from April 2, 2022, through April 
4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardioMEMS procedure (33289). 
 
You asked the Plan to pre-approve the cardioMEMS procedure. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 cardioMEMS procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. 
 
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 cardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the cardioMEMS procedure (33289).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee has not met step therapy requirements. 
 
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 that 
Prolia is not medically necessary. Our physician reviewer found that the documentation does not support that 
pamidronate and zoledronic acid injections would likely be less effective or would likely have adverse effects 
for you 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says the enrollee does not have a history of failure, 
contraindication or intolerance to injectable bisphosphonates. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of injectable 
bisphosphonates before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drugs. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.