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

 
We decided that the Plan does not have to pre-approve Eliquis Tab 5mg. 
 
You asked the Plan to pre-approve Eliquis Tab 5mg. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Eliquis Tab 5mg.  
 
Benefits for Eliquis Tab 5mg 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection of retacritprovided on May 28, 2020.You asked the Plan to pay forthe physician service. You say that the enrollee's hospice election had been terminated prior to receiving the services.The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on May 1, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe injection of retacrit provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging, tomographic (78452), 
technetium tc-99m tetrofosmin (A9502), cardiovascular stress test (93017) and regadenoson injection ( J2785) 
provided on February 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for myocardial perfusion imaging, tomographic, technetium tc-99m tetrofosmin, 
cardiovascular stress test and regadenoson injection. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-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 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 the myocardial perfusion imaging, tomographic 
(78452), technetium tc-99m tetrofosmin (A9502), cardiovascular stress test (93017) and regadenoson injection 
( J2785) provided on February 11, 2020 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 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 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires or can tolerate an 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter occlusion/embolization for tumor 
destruction (S2095). 
 
You asked the Plan to pre-approve CPT code S2095. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says transcatheter occlusion/embolization for tumor destruction 
with CPT code S2095 is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. In this case, CPT code S2095 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of and payment for, this service. Therefore, we decided that the Plan does not have 
to pre-approve transcatheter occlusion/embolization for tumor destruction (S2095).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician 
evaluation.  The enrollee's care needs can be met at a lower level of 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network mental health 
specialist. 
 
You asked the Plan to pre-approve continued care with an out-of-network mental health specialist. You say that 
continued care with out-of-network mental health specialist is medically necessary. The Plan denied your 
request. The Plan says continued care with out-of-network mental health specialist is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve continued care with an out-of-network 
mental health specialist. Our reviewer says that continued care with out-of-network mental health specialist is 
not medically necessary. Our physician reviewer found the enrollee suffered from Posttraumatic Stress 
Disorder. Based on review of the records provided, it is noted that this enrollee has seen the therapist since 
October 15, 2019 with the focus of psychotherapy on her symptoms of PTSD.  There is no documentation of 
 
 
treatment failure or the inability of this enrollee to attend treatment in network other than believing that there is 
continuity of care. The medical plan has stated the only reason for seeing an out of network provider is in 
urgent/emergent condition or if a therapist is not available in network. Based on review of the records provided 
this enrollee does not require treatment by an out-of-network provider as the medical plan is able to provide a 
psychotherapist for the treatment of this enrollee's condition. This enrollee's condition is not considered 
urgent/emergent condition. Utilization of a network provider assures a credentialed and clinically maintained 
individual assured by the medical provider to a certain standard of 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 continued care with an out-of-network mental health specialist have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network 
mental health specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (CPT Code E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the durable medical equipment 
(DME) is necessary. The Plan denied your request. The Plan says the DME is not 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 semi-electric hospital bed. Our 
physician reviewer found a semi-electric hospital bed is not medically necessary per LCD L33820. The 
documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible 
in an ordinary bed or why positioning of the bed in other ways is not feasible. You do not require the head of 
the bed to be elevated more than 30 degrees due to congestive heart failure (CHF), lung problems or aspiration 
issues. The documentation does not support a need for an immediate change in body position or special 
attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
 
 
Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side 
rails, with mattress (CPT Code E0260).
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) (22514). 
 
You asked the Plan to pre-approve PVA. 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 follows Medicare rules. Medicare rules say that PVA is covered when certain criteria is 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 PVA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found recent literature does not support the role 
of kyphoplasty in treating lumbar compression fractures. Also, there is no documentation of an adequate trial 
and failure of conservative measures such as bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA) (22514).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to be able to perform fifteen hours per week of rehabilitative services.  The enrollee's care needs can 
be met at a lower level of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a JAK2 (V617F variant) gene analysis, a CALR gene 
analysis, and an MPL gene analysis. 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says JAK2, CALR and MPL gene analysis testing can be 
covered if another genetic test, BCR-ABL gene analysis, is done first and the test result is negative. The file 
does not show that the enrollee has had a BCR-ABL gene analysis with a negative result. Therefore, we 
decided that the Plan does not have to pre-approve a JAK2 (V617F variant) gene analysis, a CALR gene 
analysis, and an MPL gene analysis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is 
unclear the number of prior injections the enrollee has had. 
 
The Plan follows Medicare rules. Medicare rules say that facet injection are only covered under certain medical 
indications. 
 
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 services. Our physician 
reviewer found that you have a history of chronic low back pain, status post lumbar decompression, failed back 
syndrome, and lumbar spondylosis. Although you have a history of axial pain and has previously undergone 
lumbar surgery, you experienced 60% pain relief after a diagnostic facet injection. Per the policy guidelines, a 
second medial branch block is recommended when there is greater than 80% relief from the prior injection. As 
such, your clinical presentation does not meet the criteria.  In addition, you had multiple facet injections with 
relief, but there was no documentation as to the number of prior facet injections performed. Given that the 
number of prior injections is unclear, the request is not considered medically necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet joint blocks.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial lower denture. You say that the item is necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 a partial 
lower denture when the services are medically necessary and reasonable. 
 
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 partial lower denture. Our reviewer 
says that the item is medically necessary. Our physician reviewer found given the presentation of this case, 
there appears to be a good periodontal prognosis given your age and the current bone levels are such that a 
removable prosthesis would be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a partial lower denture have been met. Therefore, we decided that the Plan has 
to pre-approve a partial lower denture (D5214).  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinterrogation device evaluation (93297) provided on March 24, 2020.You asked the Plan to pay forthe interrogation device evaluation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 93297 is a column II code to column I code 93296 which has previously been processed and paid.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, we have confirmed that code the interrogation device evaluation has abundled relationship with code 93296 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forinterrogation device evaluation (93297) provided on March 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is not on the inpatient only procedure list. There were no clinical 
indicators listed in the documentation or explanation made by the treating physicians as to why inpatient care 
would be needed following this procedure for this enrollee. As observation status is approved, this should be 
sufficient unless complications or other factors arise which warrant inpatient status. Therefore, this request for 
inpatient services will be considered not medically 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.