Persius/hicric huggingface dataset:
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 records show that you were 
admitted to the hospital on August 26, 2020 with abdominal pain, nausea, and vomiting due to a small bowel 
obstruction. You were treated surgically on August 27, 2020. Your therapy is limited by fatigue and decreased 
endurance, but you are otherwise medically stable. You have no complex medical, nursing, or rehabilitation 
needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require an intensive therapy program at an IRF. The IRF services are 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy with chemical adhesive. 
 
You asked the Plan to pre-approve these services. 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. Medicare rules say that endovenous ablation 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 fairly recently 
undergone numerous chemical adhesive ablation procedures including both greater saphenous veins (the target 
structure for the current appeal) and bilateral short saphenous veins.  It is unclear what response the patient had 
to all these procedures. It is unclear if the patient had an early recurrence (or non-treatment) of reflux in both 
proximal greater saphenous veins that, if true, supports the health plan?s concerns about efficacy. Additionally, 
the assessment and plan for the upcoming procedure makes no mention that the enrollee has already undergone 
greater saphenous vein closure procedures or how the requested procedures would be modified to 
accommodate for the closed portions of greater saphenous vein bilaterally. The records also do not support that 
the criteria for coverage are met. The services are 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 endovenous ablation therapy with chemical adhesive.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
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 would like reconsideration because IRF care is 
medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare 
coverage criteria. 
 
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. Our 
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  There are no 
complex nursing or rehabilitation needs. There is not a reasonable expectation that this member 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Quetiapine Fumarate ER. 
 
You asked the Plan to pre-approve the Quetiapine Fumarate ER. You say that you would like reconsideration 
because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
for the member's condition under Medicare 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 Quetiapine Fumarate ER.  
 
Benefits for the Quetiapine Fumarate ER 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 you would like reconsideration because the member 
would benefit from acute inpatient rehabilitation care that cannot be accomplished at a lower level. The Plan 
denied your request. The Plan says the member does not meet Medicare criteria for admission to acute inpatient 
rehabilitation. 
 
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 
complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or 
rehabilitation needs. Our physician reviewer found there is no need for an intensive rehabilitation program. 
There is not a reasonable expectation that this member 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar 
spine (72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found insufficient clinical information was 
provided to determine if MRI would be indicated here. The MRI was recommended by radiology based on the 
findings of a CT scan to look for other possible lesions in the spine, however, physical examination, history of 
symptoms and an x-ray would need to be completed prior to considering this advanced imaging. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar spine (72148).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Repatha Sureclick.
Benefits for these services 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that the services should be paid. The Plan denied your 
request. The Plan says the member exhausted their 100 day SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 10, 2020 
through August 27, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 to an out-of-network orthopedic surgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4mg Dexamethasone Tablets. 
 
You asked the Plan to pre-approve the Dexamethasone. You say that you would like reconsideration because 
this drug is medically necessary. The Plan denied your request. The Plan says this medication falls under Part 
D coverage, but the member does not have a Part D Pharmacy benefit with the Plan. 
 
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 4mg Dexamethasone 
Tablets.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest and CT scan of the 
abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
abdominal pain and reported weight loss. The medical necessity for the CT scan of the chest and CT scan of the 
abdomen/pelvis is supported in the submitted records. It is not reasonable for you to undergo other procedures 
to get the CT scans. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the chest and CT scan of the abdomen/pelvis.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 obstructive 
pulmonary disease (COPD). She has not tried and failed the Plan's required drug, Perforomist. The records do 
not support that the required drug is contraindicated or less effective; therefore, the Brovana 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 Brovana.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted evaluation and management service (94999). 
 
You asked the Plan to pay for the unlisted service. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider is unable to confirm what 
procedure is being requested.
 
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 94999 is unlisted evaluation and management service. 
 
We find that CPT code 94999 is not supported in the record. Specifically, the documentation submitted does 
not show what service the unlisted service code is being used for. Based on this information, we decided that 
Medicare rules for coverage of the unlisted service have not been met. Therefore, we decided that the Plan does 
not have to pay for an unlisted evaluation and management service (94999).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergency ambulance transport. 
 
You asked the Plan to pre-approve these services. You say that you need transportation to dialysis. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 submitted records do not show that 
you are unable to sit in a wheelchair and travel by wheelchair van. There is no documentation to support that 
the ambulance level of transport is reasonable or medically necessary for you at this time. 
 
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 non-emergency ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic 
connection (E2377, E2313, E2311), gel pads (K0108 x 2) and an elevating leg rests system (E0990, E1010). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection (E2377, 
E2313, E2311), gel pads (K0108 x 2) and an elevating leg rests system (E0990, E1010). You say that the 
enrollee's current wheelchair does not work properly and does not hold a charge. The Plan denied your request. 
The Plan says this request is partially approved as medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an expandable controller with harness and electronic connection (E2377, E2313, E2311), gel pads 
(K0108 x 2) and an elevating leg rests system (E0990, E1010) have not been met. A single unit of E1010 
represents a pair of power elevating leg rests (the Plan approved one unit). The request for two units (2 pairs) of 
power elevating leg rests exceeds the enrollee's need. The Elevating Leg Rest Assembly is included with the 
requested E1010 Power Leg Elevation System, Including Leg Rest, Pair. The gel pads at issue in this appeal do 
not serve a purpose that is primarily medical in nature and are therefore not a covered benefit. The approved 
power options come with their own switches, which means an Expandable Controller with harness and 
electronic connection accessory are not needed in this case. Therefore, we decided that the Plan does not have 
to pre-approve a group 3 power wheelchair (K0862) and accessories (E2363, E1028, E1007, E2620, E0955, 
E1028 x4, E2604, E1020, E0953, E1010, K0040, K0038, E2377, E2313, E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity pen. 
 
You asked the Plan to pre-approve Trulicity pen. You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says this drug is 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 Trulicity pen.  
 
Benefits for Trulicity pen 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 long term acute care hospital (LTACH) services. You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.

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 required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not 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 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.