Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto tablets. 
 
You asked the Plan to pre-approve Entresto tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Entresto tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto tablets.  
 
Benefits for Entresto tablets 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: 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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. 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. The enrollee was treated for a fracture of the right lower leg. 
The enrollee is now living in a skilled nursing facility. 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, in an intensive rehabilitation therapy program. The record does support a need for physical and 
occupational therapy but there is no need for an intensive rehabilitation 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 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
osteomyelitis of the foot/toe. The enrollee underwent an amputation and continues to receive wound care and 
antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Irinotecan, Fluorouracil, Leucovorin Calcium, 
and Bevacizumab. 
 
You asked the Plan to pre-approve chemotherapy drugs. You say that you are appealing based on medical 
necessity. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, 
because this is a request for an off-label use that is not supported by Medicare-designated drug compendia, 
peer-reviewed literature, or listed as a standard treatment option in generally accepted textbooks. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 chemotherapy drugs. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested combination of Irinotecan, Fluorouracil, 
Leucovorin Calcium, and Bevacizumab. Our physician reviewer found the requested combination of drugs is 
not approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. The requested drug 
combination is not supported by any major drug compendia or by clinical research that appears in a Medicare-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chemotherapy drugs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of Irinotecan, Fluorouracil, Leucovorin Calcium, and Bevacizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider from December 3, 2019, to December 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider from 
December 3, 2019, to December 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on February 18, 2020. 
 
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 procedure code J7327 is not supported. 
 
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 J7327 is hyaluronan or derivative, monovisc, for intra-
articular injection, per dose. 
 
We find that CPT code J7327 is not supported in the medical record. Specifically, the records show that an 
injection of triamcinolone acetonide was administered and there is a more appropriate code for these services. 
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 injection services rendered on February 18, 
2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says that rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 
enrollee meets criteria for the requested SNF care. Our physician reviewer found that the enrollee is now 
weight-bearing as tolerated on the right lower extremity. The enrollee required contact guard assist for sit to 
stand and to transfer. She ambulated 80 feet with a front-wheeled walker. It is noted that the enrollee is not yet 
independent, and needs therapy for continued strength, balance, endurance, bed mobility, transfer, and gait/stair 
training. It is medically reasonable and necessary to provide these skilled nursing or skilled therapy services a 
daily basis. As a practical matter, the enrollee in this case requires daily skilled therapy on an inpatient basis in 
an SNF. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
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 pre-approve six additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that the enrollee is unable to maintain 
independence due to decreased endurance. The Plan denied your request. The Plan says the plan has no 
contractual obligation to cover services that are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided, there is no documentation that 
the six additional requested therapy visits are generally accepted as specific and effective therapy for the 
enrollee's condition. The enrollee has improved with the therapy she has received and transition to the home 
exercise program appears to be most appropriate at this point. There is no documentation that the unique skills 
of a professional therapist are required to safely and effectively provide the additional requested treatment, that 
the services can be safely and effectively performed only by a therapist or by or under the supervision of a 
therapist. 
 
 
 
 
 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography (CTA). 
 
You asked the Plan to pre-approve a CTA. You say that the requested CTA is medically necessary. The Plan 
denied your request. The Plan says that the requested CTA is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CTA. Our reviewer says that the 
requested CTA is medically necessary. Our physician reviewer found the documentation supports the medical 
necessity of the study in question.  To date, there has been no follow-up study of the splenic artery aneurysm. It 
is true that the growth rate tends to be slow and the rupture risk of a splenic artery aneurysm less than 2cm is 
low.  However, without a follow-up study with which to compare, one can't make a prediction about this 
enrollee's particular growth rate or rupture risk.  Once this currently ordered study is complete, an assessment 
can be made about growth rate and a plan made for future studies formulated. 
 
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 CTA have been met. Therefore, we decided that the Plan has to pre-approve a 
computed tomography angiography (CTA).  
 
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 pre-approve 4 additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve 4 additional OT visits. You say that additional visits are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for additional visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional OT visits. Our reviewer 
says that additional skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found in the absence of any documentation by a therapist in 
the form of response to therapy, the enrollee does not meet criteria. In addition, the enrollee's range of motion 
and strength are functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional occupational therapy (OT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88342, 88305) provided February 21, 
2020. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says services are not supported for payment as billed. 
 
The Plan must follow Medicare rules. The rules say that certain conditions have both an underlying etiology 
and multiple body system manifestations due to the underlying etiology. For such conditions, the underlying 
condition should be sequenced first, if applicable, followed by the manifestation. Wherever such a combination 
exists, there is a use additional code note at the etiology code, and a code first note at the manifestation 
code 
 
We find that CPT codes 88342 and 88305 are not supported for payment. Specifically, the record shows that 
these services were billed with a diagnosis of code of S22.000S. This diagnosis code has a Code First note. 
This means that it should be sequenced with an etiology code. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (88342, 88305) provided February 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee appears to be at the highest level of function realistically attainable, and 
within the context of his disability. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the 10 additional requested visits are generally accepted as specific and 
effective therapy. You are at your highest level attainable. Further work with a home exercise program appears 
indicated at this time. Based on the medical records provided there is no documentation that the unique skills of 
a professional therapist are required to safely and effectively provide the ten additional treatments, that the 
services can be safely and effectively performed only by a therapist or by or under the supervision of a 
therapist. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has been hospitalized as an 
inpatient for congestive heart failure. The Plan denied your request. The Plan says the efficacy of the device is 
uncertain, and not recommended for the treatment of heart failure. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of hypertension, smoking, diabetes, Crohn's disease, ischemic 
cardiomyopathy (stent placement), defibrillator placement and NYSHA Class III congestive heart failure with 
reduced LV ejection fraction. In this circumstance therapy change based on data obtained from a CardioMEMS 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met as the device is considered experimental or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a history of atrial 
fibrillation and urinary tract infection, who presented with abdominal pain, nausea, weakness and unsteadiness. 
He was diagnosed with paroxysmal AF, UTI and pneumonia. The enrollee uses a front wheeled walker at 
baseline. On 8/31/20, the enrollee ambulated 100 feet x 2 with a front wheeled walker. The documentation does 
not support that it is medically reasonable and necessary for the enrollee in this case to receive skilled services 
on a daily basis in a SNF. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).