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

 
We decided that the Plan does not have to pay for screening services provided to the enrollee on December 20, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says CPT code 77081-26 was denied because it was reported as a screening study for a 
female. Per the American College of Radiology and the International Society for Clinical Densitometry, 
screening bone densitometry is not indicated for a female without risk factors for osteoporosis.  
 
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 records provided do not support 
the services billed. This code is not covered as a screening. Medicare rules for coverage of this service have not 
been met. Therefore, we decided that the Plan does not have to pay for screening services provided to the 
enrollee on December 20, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from April 1, 2020 to April 3, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says there is no 
evidence that an inpatient skilled level was required for the member to maintain current level of function. The 
member was no longer benefiting from daily skilled therapy services and the stay appeared more custodial. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. 
She tolerated a regular diet and fluid restriction. She had dressings to her ankles, sacrum and posterior thigh. 
Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and 
occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a minimal to maximal assist 
level with functional mobility including gait to short distances. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided from April 1, 2020 to April 3, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for small bowel 
obstruction and respiratory failure. Medical conditions are now stable. There are no complex nursing or 
rehabilitation needs. The patient 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 need for physical and occupational therapy services, it does not support a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient mental health care to start on 
September 11, 2020. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of September 
11, 2020 forward as this patient was not shown to be a danger to themselves or others. The patient was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional inpatient mental health care to start on September 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for surgery at an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services are not emergent or urgent. 
 
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 referral for surgery at an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for an elective total hip replacement 
surgery. 
 
You asked the Plan to pay for the inpatient admission. You say that the enrollee's particular condition and 
living situation should support that same-day discharge from this surgery is not appropriate. The Plan denied 
your request. The Plan says the enrollee can be admitted as outpatient and converted to inpatient if clinically 
indicated post surgery. 
 
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 the inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee is a female with cognitive issues and hip arthritis. She is to be admitted 
on 9/23/20 for an elective left total hip arthroplasty. The review indicates that the enrollee does not require any 
inpatient diagnostic studies or therapeutic interventions. The record does not show that the admitting physician 
reasonable expects that the patient's necessary hospital care will 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 the inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient admission for an elective total hip replacement surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romiplostim (NPlate). 
 
You asked the Plan to pre-approve NPlate. The Plan denied your request. The Plan says the use of the drug 
requires a platelet count of less than 50,000/mcL, and an insufficient response to corticosteroids and 
immunoglobulins. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 NPlate. Our physician reviewer found 
that the use of the requested drug is not FDA-approved for the enrollee's diagnosis. It is listed as not indicated 
given platelets of less than 50 without bleeding issues. The documentation does not support that the requested 
drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPlate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Romiplostim (NPlate).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance company keeps billing you. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 January 3, 2020. 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRAs. 
 
You asked the Plan to pre-approve MRAs. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are 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 MRAs. Our reviewer says that the 
documentation does not support that the requested MRA is medically reasonable or necessary. Our physician 
reviewer found the enrollee has neuropathy but the history of chronic dizziness does not qualify as a symptom 
requiring MRA of the neck and brain. There is no history of headache or focal neurological symptom. Also, a 
carotid/vertebral ultrasound of the neck has not been done and there is no bruit documented on PE. Therefore, 
the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve MRAs.
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 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 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 
services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. The enrollee does not appear to be 
functioning at his baseline or to have reached a plateau in function with therapy. Daily skilled services are 
required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs at this point, as a practical matter, cannot be provided 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual therapy techniques, therapeutic procedures, and 
ultrasound therapy to be provided by a chiropractor. 
 
You asked the Plan to pre-approve manual therapy techniques, therapeutic procedures, and ultrasound therapy 
to be provided by a chiropractor. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve manual therapy techniques, therapeutic procedures, and ultrasound 
therapy to be provided by a chiropractor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp injections. 
 
You asked the Plan to pre-approve the requested Aranesp treatment. You say that the enrollee cannot use blood 
transfusions and has severe anemia. Continued Aranesp injections are required to combat anemia. The Plan 
denied your request. The Plan says this medication is not supported for anemia caused by GI blood loss. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the requested Aranesp treatment. Our 
reviewer says that the requested use of Aranesp is not considered medically reasonable and necessary. Our 
physician reviewer found this review relates to a request for Aranesp to treat severe anemia due to GI blood 
loss and very low iron in a 43-year-old man who refuses transfusions for religious reasons. The requested use is 
not FDA approved. The use is not supported in any of the CMS approved compendia. This reviewer did not 
find any supporting citations in a PubMed search. 
 
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 Aranesp treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Aranesp injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation anesthesia services. 
 
You asked the Plan to pre-approve these services. You say that you would like to have anesthesia for the tooth 
extraction. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation anesthesia services.
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 the SNF admission. You say that it is felt that the enrollee has not fully 
recovered and cannot be sent home until he is fully able to care for himself. The Plan denied your request. The 
Plan says the enrollee has no skilled nursing needs and is not likely to benefit from daily skilled therapy. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted for 
treatment of a non-ST elevation heart attack and was discharged to IRF on 9/2/2020. Discharge is now planned 
from the IRF by 9/21/2020. Admission to SNF is requested for after leaving the IRF. 
 
The enrollee is requiring only supervision for all care. There are no complex wound care needs or IV 
medication requirements. There are no nursing or therapy needs that are skilled which warrant a SNF as 
opposed to a lesser level of care (including home health care services). 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Pegfilgrastim-cbqv for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is insufficient data to recommend use of multi gene assay panels to determine 
adjuvant chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the plan is for this 
enrollee to receive FOLFOX chemotherapy for her high risk stage II colon cancer. Given that FOLFOX is 
associated with an intermediate risk of neutropenic fever and she is older than 65 years of age her risk of 
neutropenic fever is likely more than 20% and the prophylactic use of growth factors is recommended. The use 
of Pegfilgrastim-cbqv is reasonable and 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Pegfilgrastim-cbqv for the enrollee.  
 
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.