Persius/hicric huggingface dataset:
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 your health would be jeopardized if you continued 
rehab from home. The Plan denied your request. The Plan says the denial of authorization for SNF care is 
correct. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be improving and should only require short-term additional acute care 
hospital services that can be safely administered at the current facility until appropriate for a lower level of care 
such as a skilled nursing facility. There are no services at the LTACH that you require that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment is 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 long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (romosozumab-aqqg) injections. 
 
You asked the Plan to pre-approve the Evenity treatments. You say that it is felt that the criteria for use of 
Evenity have been met. The Plan denied your request. The Plan says the enrollee must be trialed with the 
preferred drug before Evenity can be approved. 
 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 Evenity treatments. Our reviewer 
says that the requested use of Evenity is not medically reasonable and necessary based on the step therapy 
rules. Our physician reviewer found the enrollee is a 71-year-old female with a diagnosis of osteoporosis and a 
history of left femur and left humerus fractures. Treatment with Evenity injections have been requested. Based 
on the medical records provided, the patient has not tried and failed the required drug, Forteo (teriparatide). 
There is no indication that the plan's required drug would likely be less effective and/or likely have adverse 
effects for the patient. 
 
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 Evenity treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Evenity (romosozumab-aqqg) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-spinal electrical osteogenesis stimulator 
(E0747). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that you would like reconsideration 
because this will prevent future complications and surgeries. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator 
(E0747) is covered when there is evidence of a nonunion of a long bone fracture. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the osteogenesis stimulator have not been met. Specifically, the documentation indicates that the 
osteogenesis stimulator is being requested for nonunion of a patella fracture. The patella is not considered a 
long bone per LCD guidelines. Therefore, we decided that the Plan does not have to pre-approve the non-spinal 
electrical osteogenesis stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to these services would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services provided on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that you need a nurse for assistance. The 
Plan denied your request. The Plan says you are not homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
We looked at the file and the rules. The file does not show that you are homebound. The records show that you 
are able to leave the home for medical appointments. Based on this information, we decided that the Medicare 
rules for coverage have not been met.  Therefore, we decided that the Plan does not have to pre-approve home 
health skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care Diagnosis Related Group (DRG) 477 
provided from January 23, 2019, to January 28, 2019. 
 You asked the Plan to pay for inpatient hospital care. You say that the Plan failed to pay for this stay at the 
appropriate rate. The Plan denied your request. The Plan says the denial of payment for DRG 477 is correct, 
because diagnosis code J18.9 is not supported so DRG 478 is appropriate instead. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J18.9 - pneumonia, unspecified organism. 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 inpatient hospital care. Our reviewer says that this 
inpatient stay does not meet the criteria for payment at DRG 477. Our physician reviewer found the 
documentation does not support a definitive diagnosis of pneumonia. Radiology reports on January 24, 2019 
document suspicion for pneumonia; however, no further testing to confirm this diagnosis was performed. Also, 
documentation throughout this stay is not consistent for care and treatment of pneumonia. This diagnosis code 
is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care Diagnosis Related Group (DRG) 477 provided from January 23, 2019, to January 28, 
2019.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline. The enrollee 
does not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on October 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
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 85060 is not supported in the medical record. Specifically, code 85060 is assigned a 
PCTC indicator of 8. The services were billed with place of service 22 (outpatient hospital). No payment is 
recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 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 pay for the services (85060) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve food thickener. 
 
You asked the Plan to pre-approve food thickener. You say that food thickener is medically necessary. The 
Plan denied your request. The Plan says the requested product is not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
The rules say that food thickeners (B4100), baby food, and other regular grocery products that can be 
blenderized and used with the enteral system will be denied as non-covered. Although these may be appropriate 
for your use, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve food thickener.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled physical therapist to make more home 
visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found the the documentation 
doesnt support that the enrollee requires additional skilled rehab services to provide treatment that is medically 
necessary. The enrollee does not require additional rehab services to effectively provide treatment, care, and/or 
services in order to improve the members condition, perform a maintenance program to maintain the 
members condition and/or prevent deterioration.  The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 13 home health physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0394T) provided from September 15, 2021, to 
September 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
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 0394T 
is a column II code to column I code 77401. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (0394T) provided from September 15, 2021, to 
September 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (onabotulinum toxin A) injections. 
 
You asked the Plan to pre-approve the Botox injections. You say that you need this treatment to help with your 
condition. The Plan denied your request. The Plan says this specific drug is not covered because there has not 
been a trial of the preferred agents. 
 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 Botox injections. Our reviewer says 
that the requested Botox injections are reasonable and necessary based on step therapy criteria. Our physician 
reviewer found the enrollee has a diagnosis of torticollis with muscle spasm. The case file does not contain 
documentation of trial and failure of preferred agents, Dysport (abobotulinumtoxinA) or Xeomin 
(incobotulinumtoxinA). The documentation does not support that these preferred agents would likely be less 
effective, and/or would likely have adverse effects for the enrollee 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 Botox injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Botox (onabotulinum toxin A) injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 
You asked the Plan to pre-approve the Durolane injections. You say that it is felt that the requested drug is 
medically necessary. The Plan denied your request. The Plan says there has been no trial/failure of the 
preferred drugs for this 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 Durolane injections. Our reviewer 
says that the requested drug is not considered medically necessary based on step therapy criteria. Our physician 
reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. The case file 
does not contain documentation of trial and failure of Orthovisc, Synvisc, or Synvisc One. The documentation 
does not support that Orthovisc, Synvisc, or Synvisc One would likely be less effective, and/or would likely 
have adverse effects for the enrollee 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 Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections.
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. The Plan denied your request. The Plan says you do not require an 
intensive multidisciplinary approach to daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 you were admitted to the acute care hospital for congestive heart failure and non-surgical management of 
pelvic fractures after a fall. Your medical problems are stable. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says guidelines recommend at least 6 months must elapse since last 
injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of osteoarthritis of the knees. The Food and Drug Administration has stated 
that the requested drug is indicated for the enrollee's condition. The record indicates that the enrollee completed 
a series of viscosupplementation injections less than six months ago in December 2021 and had good relief.  
The record does not support the medical necessity, as defined by Medicare rules, of the requested service at this 
time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair (omalizumab). 
 
You asked the Plan to pre-approve the Xolair. You say that this is necessary to treat the enrollee's allergic 
asthma symptoms. The Plan denied your request. The Plan says this was requested to be obtained at the 
pharmacy and brought to the office for administration. As such, it must be covered by a Part D plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, the Plan has indicated that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xolair (omalizumab).