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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs more strength in his legs 
before going home. The Plan denied your request. The Plan says the enrollee has not skilled nursing or therapy 
needs. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee had stable vital signs, and received oral medications. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a standby assist 
level with functional mobility. He required varying assist with activities of daily living. Although there are 
identifiable skilled therapy service needs, he does not require skilled nursing or therapy services on a daily 
basis. He does not meet severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are considered 
medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four 
times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin 
dosage based on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no 
continued skilled medical needs. 
 
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 services. Our physician reviewer 
found that the enrollee is walking with contact guard assistance using a rolling walker, is at contact guard assist 
for transfers, and moderate to maximum assist for activities of daily living. There is no report of any medically 
unstable conditions. The enrollee does not require skilled nursing or therapy services of a skilled professional 
on a daily basis. The enrollee does not require necessary services 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of NYHA 
Class III congestive heart failure with recovered left ventricular ejection fraction (LVEF of 50 percent) 
requiring hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission 
compared to standard medical therapy. The services are considered experimental in nature and are not the 
standard of care. The CardioMEMs is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing the Plan's denial. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this 
drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D 
prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although Medicare Part B covers oral anti-emetics associated with cancer chemotherapy 
under certain conditions, this request does not meet those conditions because the requested drug is not being 
used as a full therapeutic replacement for intravenous anti-emetic therapy that would have otherwise been 
administered at the time of chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-
approve prochlorperazine tablets.  
 
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro 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 this is not being requested for a medically necessary indication. 
 
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 not medically reasonable or necessary. Our physician reviewer found Neulasta is indicated 
for chemotherapy-induced neutropenia prophylaxis, to decrease the incidence of febrile neutropenia, in patients 
with nonmyeloid malignancies receiving myelosuppressive chemotherapy associated with a clinically 
significant incidence of febrile neutropenia. The review has determined that the documentation does not 
support that the drug is medically reasonable or necessary for the enrollee. The documentation does not support 
that the drug is safe and effective for the 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta Onpro for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for teeth 19 and 20 (D2750). 
 
You asked the Plan to pre-approve the crowns for teeth 19 and 20. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says you have exceeded limits set in 
the subscriber agreement. 
 
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, your request exceeds the Plan's benefit 
limit. Specifically, the Plan's benefit covers two crowns per year.  The record indicates that the Plan has 
approved two crowns on teeth 6 and 7. This request exceeds the two crowns per year limit. Therefore, we 
decided that the Plan does not have to pre-approve crowns for teeth 19 and 20 (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recement of a crown (D2920) provided on October 1, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you asked for the additional dental coverage 
when you enrolled in the plan. You say that it was not effective until November 1, 2020. You say that you did 
not fill out an application, but enrolled over the phone. You say that when you went to the dentist, you were 
advised that you had the regular standard coverage and not the dental rider. You also say that someone dropped 
the ball. The Plan denied your request. The Plan says recement of crown is listed as a class 3 major dental 
service. The Plan says that you pay 100% for class 3 major dental services. The Plan also says that your request 
to enroll in the Plan's dental option was received on October 9, 2020 and processed to be effective on 
November 1, 2020. 
 
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 recement of a crown requires a 
member liability of 100%. Additionally, the record shows that you signed up for the plan using CMS's online 
enrollment center, which does not offer a dental option as part of enrollment. Therefore, we decided that the 
Plan does not have to pay for the recement of a crown (D2920) provided on October 1, 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. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. 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. He was admitted for right-sided weakness and treated for a 
stroke. His medical conditions are stable. There are no complex nursing or rehabilitation needs. He does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 
 
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 admission to a long term acute care hospital 
(LTACH) for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says ongoing care needs can be met in a lower level of care. 
 
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 appears to be more stable but requires only a short extension of acute 
care services for weaning and PT which can be safely administered at the current facility. The enrollee does not 
require services at the LTACH that are not already available and covered at the current facility. Therefore, this 
request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level 
of care may be considered when treatment has completed and weaning has completed. 
 
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 an admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genomind Professional PGx Express testing provided 
on June 13, 2020. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration 
because this testing was deemed medically necessary. The Plan denied your request. The Plan says this service 
has not been billed correctly. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the pharmacogenomic testing, was requested solely for screening purposes. The 
documentation does not show that the requested pharmacogenomic testing was ordered due to any 
signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-
making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have 
to pay for the Genomind Professional PGx Express testing provided on June 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee is stable and been doing well on this 
medication. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Prolia for the enrollee.  
 
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
and full leg appliance. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded E0652 is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic lymphedema. 
The documentation does not support on the treating medical practitioner progress notes objective physical 
exam findings that indicate the enrollee has lymphedema of the chest, trunk, or abdomen. There is no 
documentation of a four-week trial and failure of the standard pump with detailed measurements. The criteria 
for coverage are not met; therefore, the PCD is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 and full leg appliance.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS device. 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 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has NYHA Class III congestive heart failure with recovered LV ejection 
fraction (LVEF 55-60%) requiring hospital admission. In this circumstance therapy change based on data 
obtained from a CardioMEMS device has been demonstrated in only one randomized prospective 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. Therefore, the efficacy of the CardioMEMS device is 
uncertain at this time according to leading authorities (reference 3) and not recommended in current guidelines 
for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from April 16, 
2020, to April 22, 2020.  
 
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 this is an administrative determination for coding and is not based on clinical criteria for 
medical necessity. The Plan says that code J1642 has a status indicator equal to E on the physician fee schedule 
as an excluded code from physician fee schedule by regulation, no RVUs or payment amounts for the service 
are made for them under the fee schedule. Per the Medicare guidelines, the Medicare rule for payment of this 
code has not been met. The plan would accept a submission of a corrected claim to consider service for 
payment.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, the code submitted is excluded from 
payment on Medicare claim. Therefore, we decided that the Plan does not have to pay for physician services 
provided to the enrollee from April 16, 2020, to April 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99282) provided on 
May 15, 2020. 
 
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration 
because the right to recover for services provided to eligible beneficiaries is not extinguished by specific plan 
requirements. The Plan denied your request. The Plan says this service was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department services have not been met. Specifically, this claim has not been billed 
with the appropriate revenue code. Therefore, we decided that the Plan does not have to pay for the emergency 
department services (99282) provided on May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relistor. 
 
You asked the Plan to pre-approve Relistor. You say that the service should be covered. The Plan denied your 
request. The Plan says the service is not a covered 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 Relistor.