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

 
We decided that the Plan does not have to pre-approve Tresiba Flextouch 100. 
 
You asked the Plan to pre-approve Tresiba Flextouch 100. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Tresiba Flextouch 100 is not covered under the 
enrollee'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 Tresiba Flextouch 100.  
 
Benefits for Tresiba Flextouch 100 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient, outpatient office visit (99213-GT-U2) 
provided June 4, 2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the claim was billed with an 
invalid/missing modifier. 
 
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, procedure code 99213 GT-U2 was billed with an invalid or missing modifier. Per CMS guidelines, 
modifiers GT cannot be used with these codes. Change Request (CR) 10152 eliminates the requirement to use 
the GT modifier (via interactive audio and video telecommunications systems) on professional claims for 
telehealth services. Use of the telehealth Place of Service (POS) Code 02 certifies that the service meets the 
telehealth requirements. Based on this information, we decided that Medicare rules for coverage of the 
outpatient office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
established patient, outpatient office visit (99213-GT-U2) provided June 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection, 
chemotherapy administration, Granisetron Hydrochloride injection, and Azacitidine injection provided on May 
19, 2020. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection, chemotherapy 
administration, Granisetron Hydrochloride injection, and Azacitidine injection. You say that hospice was only 
effective from February 21, 2020, to May 1, 2020. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
enrollee's terminal condition. 
 
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 for the therapeutic,
prophylactic, or diagnostic injection, chemotherapy administration, Granisetron Hydrochloride injection, and 
Azacitidine injection provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on May 7, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on May 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs that you received while in an 
outpatient setting provided from March 12, 2020, to May 26, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you should not be responsible for the 
charges. You say that the facility would not let you bring your own medications with you. The Plan denied 
your request. The Plan says the drugs you received while in an outpatient setting are considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan says the requested drug is not covered under 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 pay for the self-administered drugs that 
you received while in an outpatient setting provided from March 12, 2020, to May 26, 2020.  
 
Benefits for the self-administered drugs 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 Prolia.  
 
You asked the Plan to pre-approve the Prolia. You say that the enrollee needs this medication. The Plan denied 
your request. The Plan says there has been no trial of zoledronic acid as required by step therapy rules. 
 
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 Prolia. Our reviewer says that the 
requested use of Prolia is not medically reasonable and necessary based on step therapy criteria. Our physician 
reviewer found the documentation does not support a history if an osteoporotic fracture or previous treatment, 
contraindication, or intolerance to zoledronic acid.   Step therapy, as outlined by the plan, requires this 
documentation.  Without the support of the documentation, Prolia is not approved as step criteria are 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a testosterone cypionate injection. 
 
You asked the Plan to pre-approve a testosterone cypionate injections. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says testosterone cypionate injections will be 
provided through your pharmacy and is therefore not covered under your 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 a testosterone cypionate 
injection.  
 
Benefits for a testosterone cypionate injections 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require daily physician visits, and is unlikely to tolerate 3 hours of therapy per day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for a cerebrovascular accident. His medical problems are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation 
that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-surgical professional services provided 
by a participating provider on June 9, 2020. 
 
You asked the Plan to waive the copayment for non-surgical professional service. You say that you do not 
think that this was an outpatient surgery. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient hospital services/outpatient hospital services.  
 
You have been asked to pay $200 which is less than your copayment amount of $300 for non-surgical 
professional service. Non-surgical professional service falls within the outpatient hospital services/outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for non-surgical 
professional services provided by a participating provider on June 9, 2020.
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 your therapy needs can continue to 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 do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for back pain after a fall. You had 
surgery for a fracture of L2 vertebra. Your medical problems are stable. There are no identified problems that 
need inpatient medical management. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazodone. 
 
You asked the Plan to pre-approve Trazodone. The Plan denied your request. The Plan says this drug is not 
covered for your condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trazodone.  
 
Benefits for Trazodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the requested 
service is available in-network. 
 
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 physical therapy services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve additional OON services. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient services for dialysis with an out-of-network 
provider. 
 
You asked the Plan to pre-approve outpatient services for dialysis with an out-of-network provider. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services 
requested are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
providers available to the enrollee that can provide the care and treatment the enrollee is requesting. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide outpatient services for 
dialysis. Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we 
decided that the Plan does not have to pre-approve outpatient services for dialysis with an out-of-network 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no evidence of need for skilled nursing care or skilled 
rehabilitation services needed on a daily basis in a SNF. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for cystourethroscopy, with insertion of permanent adjustable 
transprostatic implant; each additional permanent adjustable transprostatic implant (CPT Code 52442 x5) 
provided on November 8, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plan?s contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on the services are not 
supported by the records. Therefore, we decided that the Plan has to pay for cystourethroscopy, with insertion 
of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant 
(CPT Code 52442 x5) provided on November 8, 2019.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four physical therapy visits provided from July 31, 2020, 
through August 12, 2020. 
 
You asked the Plan to pay for four physical therapy visits. You say that it is vital to regain strength and 
function. You say that you are asking for continued coverage. The Plan denied your request. The Plan says the 
physical therapy visits were not medically necessary. 
 
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 pay for four physical therapy visits. Our reviewer 
says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you had prior therapy for this condition and were 
trained in an independent exercise program. Our reviewer says that the unique skills of a professional therapist 
were not required to safely and effectively provide ongoing treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pay for four physical therapy visits provided from July 31, 2020, through August 12, 
2020.
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 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 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 patient?s nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
patient continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesn?t support that the patient would meet criteria for admission to 
an acute inpatient rehabilitation facility. There is no indication that the patient would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain their functional status. The patient is medically stable without 
any skilled nursing needs. The patient is near their prior level of function and could receive services 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.