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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee can safely receive the services needed in another setting. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgery to treat esophageal cancer. The enrollee's medical problems are stable and there are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record does document a need for physical and occupational therapy, it does not document a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 

Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home services provided on November 1, 2019, to 
November 9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing home services. You say that your surgeon is in-network and the surgeon 
wanted you to go to this facility because he trusts them. The Plan denied your request. The Plan says prior 
authorization was not obtained by the physician or the facility. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing home services provided on November 1, 
2019, to November 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography scan (LDCT) for lung 
cancer screening (G0297) provided on January 22, 2020. 
 
You asked the Plan to pay for LDCT for lung cancer screening. You say that this should be covered. The Plan 
denied your request. The Plan says this is not covered for the enrollee's age. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung 
cancer screening with Low Dose Computed Tomography (LDCT), beneficiaries must be between ages 55 and 
77.  
 
We looked at the file and Medicare rules. The record shows that the enrollee was 83 at the time of service. 
Based on this information, we decided that Medicare rules for coverage of LDCT for lung cancer screening 
have not been met. Therefore, we decided that the Plan does not have to pay for a low dose computed 
tomography scan (LDCT) for lung cancer screening (G0297) provided on January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air ambulance transport. 
 
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 follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 show that you 
have decubitus ulcers that require extensive surgical therapy. You are receiving necessary care for this 
diagnosis and have access to necessary care via a land ambulance. The air transport does not meet the criteria 
for coverage and 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 an air ambulance transport.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended sleep study. 
 
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 a sleep study 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 difficulties with 
memory and is suspected of having Alzheimer's dementia. The clinical notes mention vivid dreams, nocturnal 
hallucinations, and talking in sleep, but there is no mention of a possible parasomnia or sleep disorder, and a 
sleep study is not included in the diagnostic plan. There is no assessment of daytime sleepiness. The medical 
records do not provide a justification for a sleep study; therefore, the 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an attended sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 30, 
2019, to November 6, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that therapy was not needed 
and you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from October 30, 2019, to November 6, 2019. Therefore, you are 
responsible to pay a $345 copayment for days 1-5 (October 30, 2019, to November 3, 2019). $345 (copayment) 
x 5 (inpatient days) = $1,725.  
 
You have been asked to pay the total copayment amount of $1,725 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from October 30, 2019, to November 6, 2019.
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 enrollee exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
based on Medicare guidelines, LTACH services do not meet the requirements for approval. 
 
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 that the enrollee was admitted to the current acute care hospital with chest pain and 
cardiac arrest. He required mechanical ventilation, dialysis, and IV antibiotics for bacteremia and pneumonia. 
He underwent tracheostomy. Weaning has initiated showing signs of improvement. He requires monitoring of 
his respiratory, renal, cardiac, wounds, and nutritional status. The enrollee appears to be improving and only 
requires short term additional acute care services (likely less than 25 days) which can be completed 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 after additional weaning and improvement. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s), if performed, 
provided on March 17  2020. 
 
You asked the Plan to pay for the Vitamin D screening procedure. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says vitamin assay panels are not covered by Medicare. 
 
The Plan must follow Medicare rules.  
 
You have requested payment for services billed under code 82306. The record does not show a qualifying 
diagnosis. Therefore, we decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes 
fraction(s), if performed, provided on March 17  2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInvokana tablets.You asked the Plan to pre-approveInvokana tablets. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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-approveInvokana tablets.Benefits for Invokana tabletsmay be available under Medicare Part D.Contactthe 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 Prolia for the enrollee.
You asked the Plan to pre-approve the drug. You say that the enrollee does not respond to oral medications as
quickly. The Plan denied your request. The Plan says the information does not meet the plan's medical
necessity guidelines for coverage.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable and necessary, and does not meet the step therapy criteria. Our
physician reviewer found the plan requires a trial of zoledronic acid before approving Prolia. This has not been
demonstrated in the records. There is no documentation indicating that the plan's required drug would likely be
less effective and/or likely have adverse effects for the enrollee. There is no history of osteoporotic fracture.
The review has determined that the enrollee does not meet the plan's medical necessity guidelines for coverage.
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 Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the records do not show 
that the source of your pain is thought to be the facet joint. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications 
listed 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 facet joint injections. Our reviewer says 
that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found 
there are been no physical examination documented to indicate that your pain is axial. Therefore, the requested 
injections are not medically reasonable and necessary 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).

You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the documentation does not support the use of this drug to treat your age-related osteoporosis.

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 Evenity. Our reviewer says that Evenity is not medically necessary. Our physician reviewer found you are a male with a wedge compression fracture.  Our reviewer found that your bone density T-score is -3.2 in the lumbar spine and -2.8 in the hip. Our physician reviewer also found that the use of Evenity is not supported for the treatment of osteoporosis in males.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.

You asked the Plan to pre-approve Xiidra eye drops. You say that the enrollee's condition has been under control with Xiidra. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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 Xiidra eye drops. 

Benefits for Xiidra eye drops 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapy at the center two times per week.

You asked the Plan to pre-approve therapy. You say that when going to the center, he was walking in the parallel bars and now he isn't walking at all. You say that you want him to walk just as much, if not more than he was walking before. The Plan denied your request. The Plan says therapy at the center is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.

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 therapy. Our reviewer says that the use of the parallel bars is not medically necessary as the enrollee's therapy can safely and effectively be met at home. Our physician reviewer found that the requested services are not necessary to improve and maintain the enrollee's overall health status.
&#8195;
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve therapy at the center two times per week.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on April 16, 2019 and 
billed under codes 90307 and G0481. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says a valid physician order and/or specific documentation to show medical necessity of this 
testing was not submitted.  
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. The Plan states 
additional medical record documentation was requested but was not received. Therefore, we decided that the 
Plan does not have to pay for drug testing provided to the enrollee on April 16, 2019 and billed under codes 
90307 and G0481.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you are in a lot of pain, have 
arthritis, and a chipped disc in your back that will never go away. You say that you will get worse without 
physical therapy. You say that the information from your doctor and the imaging shows that the requested 
services are medically necessary. The Plan denied your request. The Plan says the notes provided do not show 
a new injury, recent illness, or surgery. The Plan says that the clinical notes do not verify progressive functional 
improvement. The Plan says that the notes do not support the need for skilled physical therapy services. The 
Plan says that the medical necessity criteria for coverage. 
 
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 physical therapy services. 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 the requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy 
for this condition and it does not appear that the enrollee requires the ongoing unique skills of a professional 
therapist to safely and effectively provide treatment, or that the services can be safely and effectively 
performed only by a therapist, or under the supervision of a therapist. The enrollee has been trained in an 
independent home exercise program. The  specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided on January 6, 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 claim payment is calculated taking into consideration when payments are made by the 
auto carrier and the Plan's allowable amount.  The records show that when combined, the auto carrier payment 
and the Plan's payment should not exceed the normal Medicare allowable amount. The auto carrier paid 
$825.00 which is above the Medicare allowed amount. Therefore, the Plan has no payment requirement for this 
claim.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has identified the Medicare allowed amount for this 
service was already paid by the auto insurer.  Therefore, we decided that the Plan does not have to pay for 
ambulance transport provided to the enrollee on January 6, 2020.