Persius/hicric huggingface dataset:
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 Repatha. You say that Repatha has been requested as an additional LDL 
lowering medication. The Plan denied your request. The Plan says the drug is not covered for the enrollee's 
condition by the Part B 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 Repatha Sureclick.  
 
Benefits for Repatha 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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for altered mental status. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that inpatient rehab level of intensive therapy exceeds member's need. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to stay at HealthSouth. 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 submitted records show that 
you were admitted to the hospital on September 18, 2020 with right lower extremity pain and difficulty 
walking. You were treated with intravenous (IV) antibiotics. You also have right hip pain due to osteoarthritis 
and were working with physical and occupational therapy. You do not have complex medical, nursing, or 
rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth 
#14 (CPT Code D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any 
pins when required, tooth #14 (CPT Code D2950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc-One injection. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee must try and fail other drugs that are indicated for treating the enrollee's 
condition. 
 
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 injection is not medically reasonable or necessary. Our physician reviewer found you have not trialed 
viscosupplemental treatments such as Euflexa, Durolane, Supartz-FX, or Gelsyn-3. Step therapy, as outlined by 
the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Synvisc One is not approved as 
step criteria is not met. 
 
 
 
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 a Synvisc-One injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regneration - resorbable barrier. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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 
guided tissue regneration - resorbable barrier.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fosnetupitant 235mg and Palonosetron 0.25mg. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the records 
do not show that the drugs the enrollee is receiving has a high risk of causing nausea or vomiting, or that the 
enrollee is receiving treatments through the veins. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested drug. Our physician 
reviewer found that the requested use of the drugs is not FDA-approved for the enrollee's diagnosis. It is 
indicated for highly emetogenic regimens. Gemcitabine and Abraxane are both low emetogenic potential drugs. 
The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Fosnetupitant 235mg and Palonosetron 0.25mg.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 based on the medical records provided there is 
no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse is not required to safely and effectively provide medically necessary and 
reasonable treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist is required to safely and effectively provide medically necessary and 
reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient 
basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis or in the 
home or an assisted living facility with home health services appears appropriate in this case. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON chiropractic care. You say that this provider has a blood analysis 
program to help identify deficiencies and no other chiropractor in the area does this. You have been receiving 
care from this provider since 2005 and he has worked with your other medical providers to come up with a 
combined treatment plan. You feel that you would have to start from step one if you went to a new 
chiropractor. The Plan denied your request. The Plan says your plan requires the use of network providers. 
There are in-network chiropractors who can provide the Medicare-covered services you require. You must use 
these providers for this benefit. 
 
The rules say that the only services from a chiropractor that is covered by Medicare is the manual manipulation 
of the spine to correct a subluxation. Medicare rules also 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 manual manipulation of the spine. The services cited as unavailable from other 
chiropractors are services which would not be covered by Medicare or your plan. 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 the chiropractic services to be provided by an out of network (OON) provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided the patient does not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ear or pulse oximetry (94761) provided on March 26, 2020. 
 
You asked the Plan to pay for ear or pulse oximetry. You say that this was medically necessary. The Plan 
denied your request. The Plan says payment for this code must be packaged into payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 94761 is not supported as billed. Specifically, this code has a status indicator of N. 
Payment is packaged into payment for a separately paid service. However, this code was billed without any 
other services on the claim. It cannot be individually paid. Based on this information, we decided that Medicare 
rules for coverage of ear or pulse oximetry have not been met. Therefore, we decided that the Plan does not 
have to pay for ear or pulse oximetry (94761) provided on March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
for tooth #18 provided on March 10, 2020. 
 
You asked the Plan to pay for the core buildup. You say that the core buildup was necessary, and there are 
plans for a crown to be provided on tooth #18 in the future. The Plan denied your request. The Plan says 
benefits are allowed for a core buildup only if essential for crown retention. 
 
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, core buildups have to be performed 
together with a crown. The record shows that no crown was provided on tooth #18 on the March 10, 2020 date 
of service. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins 
when required (D2950) for tooth #18 provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lymphatics and lymph nodes imaging (78195) provided on 
April 7, 2020. 
 
You asked the Plan to pay for the lymphatics and lymph nodes imaging. You say that you would like 
reconsideration because multiple procedures were provided on the same date of service. The Plan denied your 
request. The Plan says the submitted documentation supports one unit of 78195, which was approved. 
 
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 78195 is lymphatics and lymph nodes imaging. 
 
We find that CPT code 78195 is not supported in the record. Specifically, the submitted documentation 
supports one unit of CPT code 78195. There is insufficient information to support that additional imaging 
services were rendered on the billed date of service. Based on this information, we decided that Medicare rules 
for coverage of the lymphatics and lymph nodes imaging have not been met. Therefore, we decided that the 
Plan does not have to pay for lymphatics and lymph nodes imaging (78195) provided on April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two retainers (D6548 x2) provided on January 8, 2020. 
 
You asked the Plan to pay for the retainers. You say that your bridge broke and had to be replaced. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
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 pay for the two 
retainers (D6548 x2) provided on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance (77001) provided September 21, 2019. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that the service was medically necessary. 
The Plan denied your request. The Plan says a required modifier was missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 77001 is not supported in the medical record. Specifically, CPT code 77001 has a 
Physician Fee Schedule PCTC indicator of 1. The claim did not include the required "26" modifier. Based on 
this information, we decided that Medicare rules for coverage of the fluoroscopic guidance have not been met. 
Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance (77001) provided 
September 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 30, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting. Therefore, the Place of Service (POS) code 81 indicating an independent 
laboratory setting is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on December 30, 2019.