Persius/hicric huggingface dataset:
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 proper information was given in order for you to 
be approved to go into SNF. You also say that you should have been able to go into the SNF instead of being 
sent home.  The Plan denied your request. The Plan says the request for SNF is not supported by the records we 
received.  
 
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 from a nursing perspective, you received oral medications, had vital signs and were 
treated for pain. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. You do have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen 
concentrator. 
 
You asked the Plan to pre-approve the oxygen concentrators. You say that the enrollee's O2 oxygen saturation 
qualifies for a 12-month continuous rental. The Plan denied your request. The Plan says the enrollee began 
using the oxygen concentrator in August of 2020 and will be able to continue to keep the portable oxygen 
concentrator after the 36 months are over. This has been confirmed with the plans vendor and understood that 
the enrollee will need to continue to be serviced with the concentrator until September of 2025 when the new 
authorization can begin. The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have 
been made. 
 
We looked at the file and Medicare rules. The enrollee has had the oxygen equipment for 36 months; therefore, 
the plan is no longer responsible for coverage up until the 5-year reasonable useful lifetime of the equipment. 
The enrollee can keep their oxygen concentrator and continue using it, but the supplier will be responsible for 
the cost instead of the plan. Based on this information, we decided that Medicare rules for coverage of the 
oxygen concentrators have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
oxygen concentrator and portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the pneumatic compression device (E0675) provided on 
March 22, 2023, through April 12, 2023. 
 
You asked the Plan  to pay for the pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have  to 
pay for the pneumatic compression device (E0675) provided on March 22, 2023, through April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 1 standard power operated vehicle, patient weight capacity 
up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 1 standard power operated 
vehicle. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee 
is noted to have difficulty ambulating with a walker and is at risk for falling. He was evaluated by physical 
therapy and has difficulty performing daily activities due to weakness and impaired coordination. He is 
modified independent with transfers and has good sitting balance. He has insufficient upper extremity strength 
to functionally propel a manual wheelchair. Therefore, the group 1 power mobility device or scooter is 
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 a group 1 standard power operated vehicle have been met. Therefore, we 
decided that the Plan has to pre-approve a group 1 standard power operated vehicle, patient weight capacity up 
to and including 300 pounds (K0800).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 15, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the services were medically necessary and 
should be paid for. The Plan denied your request. The Plan says these services were not urgent or emergent, 
and not referred by a 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 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 physical therapy services provided on June 15, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99347) provided on May 22, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the facility where the enrollee resides is 
responsible for obtaining the necessary authorizations. You also say that the service was rendered in good faith. 
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. 
 
The 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 home visit (99347) provided on May 22, 2023, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks are considered experimental/investigational.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, 
when performed (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time cardiac catheterization would not be considered medically appropriate 
and necessary in this enrollee's 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232) 
provided on October 30, 2021, and October 31, 2021. 
 
You asked the Plan to pay for the subsequent hospital inpatient or observation care. You say that this claim was 
originally sent in on March 24, 2022, and you would like this claim to be reprocessed. The Plan denied your 
request. The Plan says this claim was processed correctly due to the claim not being filed until February 3, 
2023 without good cause. The Plan also says that this means more than one calendar year from the date of 
service had passed before the claim was filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a claim for the subsequent hospital inpatient or observation care was not filed until 
February 3, 2023. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent hospital inpatient 
or observation care (99232) provided on October 30, 2021, and October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray and the injection services provided on June 8, 2023, 
by an OON provider.  
 
You asked the Plan to pay for an x-ray and the injection services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was 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 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 an x-ray and the injection services provided on 
June 8, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) (77370, 77470, 
G0339, G0340). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary. The Plan denied your 
request. The Plan says Medicare requirements state that SBRT is not appropriate for the enrollee's cancer at this 
point. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT is being offered as a palliative regimen for potentially curable maxillary sinus cancer in 
lieu of standard chemo-radiation with conventionally fractionated radiotherapy. In general, the use of SBRT for 
maxillary sinus cancer is not standard of care for palliation of paranasal sinus cancers. While SBRT can be 
considered in the setting of definitive re-irradiation, SBRT for upfront treatment of paranasal sinus cancers is 
not recognized by National Comprehensive Cancer Network (NCCN) guidelines, American Society for 
Therapeutic Radiology and Oncology (ASTRO) model policy or any other consensus guidelines. The LCD 
criteria are not met. The decision is not favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiotherapy (SBRT) (77370, 77470, G0339, G0340).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections. 
 
You asked the Plan to pre-approve sacroiliac joint injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 sacroiliac joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the prior sacroiliac joint 
injection performed on August 9, 2023, provided 50% pain relief for a period of 2 weeks, which does not meet 
the LCD criteria for coverage.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections.
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 appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain functional status. The 
enrollee can receive further services at a lower 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: 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 
to receive the level of care needed. 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 there is no active medical complexity. Records do not show acute rehab nursing 
needs. At the current functional level the enrollee needs physical and occupational therapy services. Document 
does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, and 
nursing needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollees rehab needs can be safely provided in an alternate and low intensity 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor segmental home mode (E0652) 
and segmental gradient pressure pneumatic appliance full leg (E0671) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor segmental home mode and segmental gradient 
pressure pneumatic appliance full leg. You say that the items should be covered. The Plan denied your request. 
The Plan says there are in-network provider available that can provide these items. 
 
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 pneumatic compressor segmental home mode (E0652) and segmental gradient pressure pneumatic appliance 
full leg (E0671) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on April 
12, 2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the services were a 
medical emergency and ask that the charges be reconsidered. The Plan denied your request. The Plan says 
without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 12, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services without transport received 
on April 12, 2023.