Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the lower extremities provided on September 
27, 2022, by an OON provider. 
 
You asked the Plan to pay for the CT scan. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says that this 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 contract also says that the POS benefit does not apply to 
diagnostic radiology 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 a CT scan of the lower extremities provided on 
September 27, 2022, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 22, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the emergency services were 
medically necessary. The Plan denied your request. The Plan says in order for a facility to receive 
reimbursement for a Medicare member, the facility must be enrolled to participate in the Medicare program. No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the 
provider or supplier is enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Therefore, we decided that the Plan does not have to pay for an emergency department 
visit provided on November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 25, 
2022, through August 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on August 25, 2022 with vertigo, 
diarrhea, nausea, and vomiting. His blood pressure, breathing, and oxygen levels were normal. His heart rate 
was initially high and returned to normal. The computed tomography (CT) scan of the brain was normal; and 
the computed tomographic angiography (CTA) scan of the head and neck were normal. His potassium was low 
and was replaced with potassium by mouth. He had an elevated troponin but the echocardiogram provided was 
normal. He was admitted to observation; his condition stabilized and improved with medical therapy and he 
was discharged home on August 26, 2022. The review has determined that the record did not show that at the 
time of the inpatient admission the admitting physician reasonably expected that the enrollees necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 25, 2022, through August 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Prolia (J0897).  
 
  Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided on September 3, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you did not have the enrollee's insurance 
information. The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 drug testing was not filed until January 18, 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 drug testing (G0482) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection with Bupivacaine provided on September 8, 2022. 
 
You asked the Plan to pay for injection with Bupivacaine. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for injection with Bupivacaine provided on September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper extremity orthosis provided on December 28, 
2022, by an OON provider. 
 
You asked the Plan to pay for the orthosis. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says that this item 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 contract also says that the enrollee may choose to use the 
Plan's POS benefit to see an OON provider for most covered services. OON providers must be Medicare 
certified and prior authorization rules still apply. 
 
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 upper extremity orthosis provided on 
December 28, 2022, by an 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 you need intensive occupational and physical 
therapy. a coordinated team of multi-disciplinary providers are medically necessary to ensure safe and effective 
treatment the medical and services though current level of care setting are limiting progress. The Plan denied 
your request. The Plan says your records do not show you need to be seen by a rehabilitation doctor at least 3 
times a week for evaluation of functional and medical goals and progress or that you need an intensive team for 
your care. 
 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 your 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: 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 the enrollee meets and/or exceeds the Medicare 
requirements for an IRF admission and you would like reconsideration based on the records submitted. The 
Plan denied your request. The Plan says the requested IRF services do not meet the requirements for approval. 
 
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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee 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 
the enrollee 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: 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 need Long Term Acute Care 
Hospital and cannot be done at nursing home but in a higher environment. The Plan denied your request. The 
Plan says it is not safe for you to leave the hospital currently because your cardiac enzymes are elevated, and 
you are complaining of chest pain. You are receiving the care you need in the hospital where you are now and 
there is no need to transfer currently. 
 
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 there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs mouthpiece ventilation, 
which is not available on a bilevel positive airway pressure (BiPAP) device. You say that the medical records 
provided support the need for the requested device. The Plan denied your request. The Plan says the ventilator 
requested would be utilizing a pressure-cycled setting which could alternatively be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS.) 
 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 criteria for coverage have not been met. Our physician reviewer found the provided records in this case 
document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. The 
provided records document that the home ventilator is being requested for use in targeted tidal volume - 
volume assured pressure support (TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. The provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G7 CGM. The Plan denied your request. The Plan says the 
enrollee does not meet the rules for approval of this device. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G7 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's admission to a Long Acute 
Care Hospital is needed. The Plan denied your request. The Plan says the enrollee's records do not show that it 
is medically safe for you to go to a long-term acute care hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 19, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 rehabilitation therapy services can be delivered in a wide variety of settings across 
the care continuum.  Post-acute settings differ in the types of available rehabilitation therapies, intensity of 
therapy, and the level of medical and nursing support.  Acute inpatient rehabilitation facilities are settings were 
complex medical needs and functional needs combine.  The requirements for admission to an inpatient 
rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three 
physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per 
week (or at least 15 hours over a seven-consecutive day period).  Additionally, an individual requires multiple 
types of therapies one of which should be physical or occupational therapy. In this case, the complexity of the 
enrollees nursing, medical and rehabilitation needs do 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. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential 
for functional improvement however, the documentation doesnt support that she 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 her 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.