Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization from September 24, 
2020 forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospitalization. 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. 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 continued inpatient psychiatric 
hospitalization. Our reviewer says that the documentation does not support that the requested continued 
inpatient psychiatric services are medically reasonable or necessary. Our physician reviewer found the enrollee 
was involuntarily admitted to the acute inpatient psychiatric hospitalization on September 10, 2020 with 
Schizophrenia Spectrum Disorder, Unspecified. Based upon review the records provided it was not expected 
this enrollee would improve in a reasonable period of time for the dates in question as the enrollee did not have 
suicidal or homicidal ideation noted. The enrollee was not showing any acute threats to safety including 
violent/aggressive behavior. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the 
enrollee did not have dangerousness to self or others. This enrollee did not appear to require inpatient mental 
health treatment beyond the date in question as the enrollee was not a danger to herself or others without any 
violent or aggressive behaviors and not showing any medical issues or side effects to medications. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in 
question. Therefore, the enrollee did not meet criteria for the requested continued 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 continued inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization from September 24, 
2020 forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a network provider. 
 
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 
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are requesting authorization to the 
skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not meet the guidelines 
for SNF services. Their needs can be safely met home with home health services, an assisted living facility 
with home health services or long term care facility with part time skilled services. 
 
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 there are no identifiable skilled 
nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy 
on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjustment of gastric band diameter (S2083) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has gained weight. The Plan denied 
your request. The Plan says that imaging does not show a technical failure of your previous surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S2083 is assigned a status indicator of "I" under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
adjustment of gastric band diameter (S2083) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth services for teeth 22 
and 23. 
 
You asked the Plan to pre-approve surgical removal of erupted teeth. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit 
limit. 
 
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. The plan covers up to three (3) 
surgical or non-surgical extractions per calendar year. 
 
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. Review of the file shows that you received removal of teeth 24, 25, 
and 26 on August 24, 2020. This means you have received three extractions this calendar year. Therefore, we 
decided that the Plan does not have to pre-approve surgical removal of erupted tooth services for teeth 22 and 
23.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutment and abutment-supported 
porcelain fused to metal crown. 
 
You asked the Plan to pre-approve prefabricated abutment and abutment-supported porcelain fused to metal 
crown. 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. 
 
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 
prefabricated abutment and abutment-supported porcelain fused to metal crown.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the magnetic resonance imaging (MRI) of the lumbar spine (72148), an 
MRI of the pelvis (72195) and lumbar and interlaminar epidural or subarachnoid lumbar injections (62323) 
provided on May 29, 2020 and June 8, 2020. 
 
You asked the Plan to pay for the MRI of the lumbar spine, an MRI of the pelvis and lumbar and interlaminar 
epidural or subarachnoid lumbar injections. You say that you tried to get a referral from your primary care 
physician but were unable to. The Plan denied your request. The Plan says that prior authorization must be 
obtained for services rendered by an out-of-network provider. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 MRI of the lumbar spine, an MRI of the 
pelvis and lumbar and interlaminar epidural or subarachnoid lumbar injections. Our reviewer says that the 
provided MRIs and lumbar injections were medically necessary. Our physician reviewer found you underwent 
services while outside treatment area due to an acute change (unforeseen) in your medical status. You could not 
get referral through the typical means due to availability issues of those you sought to contact. Your problem 
was acute and debilitating enough to seek emergent unapproved care. This happened while you were out of the 
area due to COVID precautions. 
 
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 of the lumbar spine, an MRI of the pelvis and lumbar and interlaminar 
epidural or subarachnoid lumbar injections have been met. Therefore, we decided that the Plan has to pay for 
the magnetic resonance imaging (MRI) of the lumbar spine (72148), an MRI of the pelvis (72195) and lumbar 
and interlaminar epidural or subarachnoid lumbar injections (62323) provided on May 29, 2020 and June 8, 
2020.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal device.

You asked the Plan to pre-approve a spinal 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 a spinal 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 back pain. The requested device is considered experimental. More research is needed to show safety and efficacy of the device. 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 a spinal device have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. 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. 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 a CT scan of the chest. Our reviewer 
says that the services are medically necessary. Our physician reviewer found since a suspicious finding was 
noted on a test that was not a dedicated CT, follow-up surveillance is necessary and the request for dedicated 
CT of the chest is medically reasonable and necessary. Also, as an aside the prior history of malignant tumor in 
the larynx would qualify the enrollee for a yearly CT of the chest even without the interim positron emission 
tomography/computed tomography (PET/CT). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the chest (71250).  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy services with code S9379. 
 
You asked the Plan to pre-approve home infusion therapy. You say that the enrollee needs these services to 
manage his condition. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because this home infusion therapy service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that home infusion therapy with code S9379 is not 
valid for Medicare purposes and is not covered.  
 
We looked at the file and Medicare rules. This type of home infusion therapy service is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of home infusion therapy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy 
services with code S9379.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 physical therapy visits. 
 
You asked the Plan to pre-approve 8 physical therapy visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 8 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found 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 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 participating in an independent 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 8 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on April 19, 2020. 
 
You asked the Plan to pay for the head CT interpretation. You say that the enrollee had multiple exams on this 
date and all should be paid. The Plan denied your request. The Plan says this code was billed on the same date 
of service as 70496 which was paid on a separate claim. In order to allow payment of 70450 on the same date 
of service, a modifier is required. 
 
The Plan must follow Medicare rules. Medicare rules say that Column II codes in a PTP edit pair can only be 
paid separately if there is a modifier indicator of 1 and a clinically appropriate modifier is used.  
 
In this case, the provider billed 70496 on the same date of service as 70450. 70450 is a Column II code in 
relation to 70496 and no clinically appropriate modifier was used to support separate payment. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the 
head provided on April 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta. 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that this drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered 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 Trelegy Ellipta.  
 
Benefits for Trelegy Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.