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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found as of the last covered 
day, there is no indication in the available medical records that the enrollees psychiatric symptoms could not 
be managed on a less restrictive basis. The enrollee did not express any active suicidal ideation or intent, or any 
intent to harm themselves or anyone else.  The enrollee was not exhibiting any other significant symptoms such 
as psychosis or mania.  He had no acute psychiatric issues that would require continued inpatient care beyond 
June 6, 2023.  The enrollee has chronic symptoms. The available medical records do not support that continued 
inpatient care will change these symptoms or the enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) with auto-EPAP 
(AE) or pressure support with safety tidal volume mode which could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 7, 2022, billed 
with codes 81415, 81416, and 81417. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 7, 2022, billed with codes 81415, 81416, and 81417.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on October 20, 
2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the GeneSight 
Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
GeneSight Psychotropic testing provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) billed for date of service July 
26, 2022. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue was distinctly and 
separately identifiable. The Plan denied your request. The Plan says payment for the service at issue was 
included in payment already made for the surgery services provided on the same date of service. 
 
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 denoted by code 20610 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 a physician office visit (99213) billed for date of service July 
26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on August 7, 2022, to 
August 10, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.0. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code N17.0 is not supported by the records provided. Our physician 
reviewer found that given the laboratory data provided for this admission, the patient's best current creatinine of 
2.16 would be considered baseline level. Initial presentation with Creatinine 2.60, then with consecutive 
creatinine levels of 2.37 and 2.16. There was no clinical or laboratory evidence of acute kidney failure with 
tubular necrosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on August 7, 2022, to August 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nonpneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and nonpneumatic sequential compression garment, half leg (K1033) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve nonpneumatic compression device and accessories to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
nonpneumatic compression controller with sequential calibrated gradient pressure (K1024) and nonpneumatic 
sequential compression garment, half leg (K1033) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy (63030) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a lumbar laminectomy to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 lumbar laminectomy (63030) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 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 his 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 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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of an ankle fracture. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye surgery with an out-of-network (OON) tertiary care 
provider. 
 
You asked the Plan to pre-approve eye surgery with an OON tertiary care provider. You say that you have been 
struggling with your vision for 3 years now and need surgery so that your tears can come out correctly.  The 
Plan denied your request. The Plan says there is no evidence in the medical records to support a tertiary level of 
care. The Plan says that there are non-tertiary level of care providers in-network who can treat the enrollee.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 eye surgery with an OON tertiary care 
provider. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
tertiary level of care is not medically reasonable and necessary. There are available in-network providers that 
can perform the eyelid surgery within a timely manner. There is nothing unique about the enrollee's condition 
that would make it medically necessary to see the requested OON provider. The Plan has shown that they have 
in-network providers show meet the Standard of Care required for treatment of the enrollee's condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eye surgery with an OON tertiary care provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve eye surgery with an out-of-network (OON) tertiary care 
provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xF genomics testing (81455) provided on December 2, 
2022. 
 
You asked the Plan to pay for the Tempus xF genomics testing. You say that this testing was needed without 
delay for prior authorization. The Plan denied your request. The Plan says that this testing was not medically 
necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Tempus xF genomics testing by a contract provider. The file does not show 
that the Plan provided notice that the Tempus xF genomics testing would not be covered. Under Medicare 
rules, this means the Tempus xF genomics testing is considered approved by the Plan. Therefore, we decided 
that the Plan has to pay for the Tempus xF genomics testing (81455) provided on December 2, 2022.  
 
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: 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 it is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. All medically necessary care is being 
provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.