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 clinical information provided supports the need 
for IRF care. The Plan denied your request. The Plan says IRF care is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 
was admitted for syncope and diagnosed with occipital and temporal lobe ischemia. The enrollee's medical 
problems are stable. There are no identified problems that need inpatient medical management. 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. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
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 LTACH services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the LTACH admission is not medically necessary.

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 the enrollee does not require services at the LTACH that are not already provided at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered in the current facility. Our physician reviewer also found that transfer may be considered when treatment has completed.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by Westerly Ambulance Corps Inc. on June 9, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 9, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by Westerly Ambulance Corps Inc. on June 9, 2020.
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 has ongoing and complex 
medical needs, but is also stable and suitable for transfer to an LTACH. You say that the enrollee requires close 
medical monitoring, daily physician management, and intensive skilled services. The Plan denied your request. 
The Plan says the records show that the enrollee has not finished the full course of care in the hospital. 
 
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 the enrollee's ongoing care needs include respiratory support with ventilator 
management and tracheostomy care, strict fluid balance, telemetry, surveillance laboratory studies, transfusions 
as needed for anemia, tube feeds, and therapy services. The documentation does not support that the enrollee in 
this case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from October 28, 2019 to 
October 31, 2019. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was not on hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment of covered services. 
 
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 October 2, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services 
provided from October 28, 2019 to October 31, 2019.
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 have had a massive heart attack and are stressing 
because you need aggressive rehab in order to regain your strength and walk again. You say that if you are not 
approved for the aggressive rehab, you will have a slow process of regaining your strength, which could lead to 
several home health visits and to not being able to complete your daily activities. You say that you are not 
comfortable with someone in your home during the COVID crisis. The Plan denied your request. The Plan says 
the records do not show that the enrollee needs to be seen by a rehab doctor three times a week or a 
multidisciplinary team for care. 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 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.  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole magnesium capsules. 
 
You asked the Plan to pre-approve Esomeprazole magnesium capsules. The Plan denied your request. The Plan 
says the plan does not cover outpatient prescription drugs. The Plan also says that this medication does not fall 
under Part B 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 Esomeprazole magnesium 
capsules.  
 
Benefits for Esomeprazole magnesium capsules 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for contour next test strips. 
 
You asked the Plan to pre-approve a tier exception for the test strips. You say that you would like 
reconsideration because these test strips are medically necessary. The Plan denied your request. The Plan says 
Medicare rules say tier exceptions (co-pay reductions) are not available for drugs/devices covered by Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the test strips have not been met. Specifically, the test strips are covered under Medicare Part B. 
Tier exceptions are not available for services covered by Medicare Part B. Therefore, we decided that the Plan 
does not have to pre-approve a tier exception for contour next test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve (CPT Code 20930), (22214), (22612), (22842), (63047), 
(22614), (22853) and (63048). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your records show a request for the use of implanted pieces during a spine surgery. The 
Plan states the pieces can only be approved when the spine surgery has been approved. The Plan states spine 
surgery has not been approved for you at this time and the requested service is supported when a spinal fusion 
surgery (joins the bones in your spine) has been approved. The Plan states your records do not show that a 
spinal fusion surgery has been approved for you and your records show a request for a surgery that goes with 
your main surgery. The Plan states this can only be approved when your main surgery has been approved and 
at this time, your main surgery has not been approved. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for multilevel spinal fusion are not met. There is no severe neurologic deficit or 
documented instability. There is no severe deformity other than flatback documented. Flatback surgery is 
experimental with high complication rates exceeding 40%. it should be denied. 
 
 
 
 
 
 
 
 
 
 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve (CPT Code 20930), (22214), (22612), (22842), (63047), (22614), (22853) and (63048).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan eye drops. 
 
You asked the Plan to pre-approve Lumigan eye drops. You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrolee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan eye drops.  
 
Benefits for Lumigan 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued inpatient psychiatric care from November 3, 2020, 
forward. 
 
You asked the Plan to pay for continued inpatient psychiatric care. You say that continued inpatient psychiatric 
care was medically necessary. The Plan denied your request. The Plan says rules for continued inpatient 
psychiatric care have not been met. 
 
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 pay for continued inpatient psychiatric care. Our 
reviewer says that the service was not medically necessary and reasonable. Our physician reviewer found that 
you did not require inpatient mental health treatment from November 3, 2020, as you were not a danger to 
yourself or others and did not have any auditory or visual hallucinations or behavioral issues. It does not appear 
that active treatment was taking place beyond the date in question. It does not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve your condition or for the 
purpose of diagnosis. 
 
 
 
 
 
 
 
 
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 care have not been met. Therefore, we decided 
that the Plan does not have to pay for continued inpatient psychiatric care from November 3, 2020, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab serviced provided to the enrollee and 
billed under codes 81120, 81121, 81173, 81201, 812325, 81272, 81275, 81310, 81311, 81314 and 81321. 
 
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 Medicare guidance says, Guardant360 testing requires use of CPT 81479 to report for 
liver cancer, and the appropriate DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted does not contain the 
required codes. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay 
for lab serviced provided to the enrollee and billed under codes 81120, 81121, 81173, 81201, 
812325, 81272, 81275, 81310, 81311, 81314 and 81321.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not require the complex medical 
management of a collaborative multidisciplinary treatment team approach in order to achieve medical and 
functional improvement. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. The clinical assessment in the case file does not support that the 
enrollee is reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the benefit provides coverage for the requested item when medically necessary. 
However, the information submitted doesn't meet the Plan's medical necessity guidelines for coverage. The 
member must meet the step therapy requirement. 
 
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 Durolane. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found the documentation does not support that the 
required step therapy items would likely be less effective, and/or would likely have adverse effects for the 
member 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 Durolane have not been met. Specifically, the member has not completed the 
required step therapy. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) (CPT Code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says research has not proven to be helpful and it is considered experimental or 
investigational. 
 
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 the service. 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 considered experimental/ investigational because of the wide variation in 
efficacy in the peer reviewed literature. Therefore, the request is considered not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., 
fluoroscopy or computed tomography) (CPT Code 64625).