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

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. 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 Stelara.  
 
Benefits for Stelara 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seating system tilt only (E1002), headrest 
(E0955), manual swingaway (E1028), and calf pads (E0995 x2). 
 
You asked the Plan to pre-approve power seating system tilt only, headrest, manual swingaway, and calf pads. 
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 power wheelchair accessories are covered when 
specific criteria are 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 power seating system tilt only, headrest, 
manual swingaway, and calf pads. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee has been using a manual wheelchair and does not have skin breakdown. 
She does not require slide board transfer and does not have conditions warranting calf rest pads. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seating system tilt only, headrest, manual swingaway, and calf pads have 
not been met. Therefore, we decided that the Plan does not have to pre-approve power seating system tilt only 
(E1002), headrest (E0955), manual swingaway (E1028), and calf pads (E0995 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a proven treatment at this time. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure remains experimental. More research is needed to show 
safety and efficacy. 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 intracept procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628).
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 IRF care is medically necessary for your condition. 
The Plan denied your request. The Plan says rules for IRF care have 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 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you were admitted for weakness, dehydration, and falls. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. In this case, you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. In conclusion, 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehab needs 
require inpatient rehab stay and close physician supervision. You say that the enrollee needs rehab to regain 
their maximum function. The Plan denied your request. The Plan says an IRF admission 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 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 enrollees 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watchman procedure. 
 
You asked the Plan to pre-approve the procedure. You say that the procedure is necessary. The Plan denied 
your request. The Plan says a Watchman device is necessary for patients with a documented medical reason to 
avoid anticoagulation; therefore, you do not meet these criteria. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided does not indicate that there is a history of bleeding or contraindication to 
anticoagulation. The record provided does not document that a formal shared decision-making interaction with 
an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation 
occurred. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Watchman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ibrance. 
 
You asked the Plan to pre-approve Ibrance. You say that the services are 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 Ibrance.  
 
Benefits for Ibrance 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 initial hospital care provided to the enrollee on July 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says it is not billed with appropriate modifier to indicate that denied service was rendered as a 
significant, separately identifiable 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, the CPT Code Manual definition of code 99221 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit." 
 
We find that CPT code 99221 is not supported in the medical record. Specifically, this cannot be reported 
separately within the global surgery period (same day) for CPT 15002 and CPT 15271. 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 initial hospital care provided to the enrollee on July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve he continuation of care with an out of network (OON) 
orthopedic surgeon. 
 
You asked the Plan to pre-approve the services. You say that you were unable to schedule the necessary office 
services within the authorization dates due to the holidays, and that an extension is medically necessary. The 
Plan denied your request. The Plan says since the enrollee may require additional follow-up visits to address 
post-op x-rays and a physical therapy program, it is best to transition them to an in-network provider 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that you are not 
currently receiving any active treatment and/or medical management of her condition that makes it medically 
necessary for this enrollee to continue care with the out-of-network provider as requested. There is not anything 
unique about your condition that would make it medically necessary for you to continue care with the out-of-
network provider. Your medical management and/or follow-up care can be safely transitioned to an in-network 
specialist at this time. The fracture that you sustained is a relatively common fracture, and you have undergone 
standard treatments for such. There have been no complications indicated and the rationale for continued care 
with a specific provider is not evident. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 
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 he continuation of care with an out of network (OON) orthopedic surgeon.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing is not medically 
necessary. 
 
The Plan follows Medicare rules. 
 
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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary. Our physician reviewer found that 
based on review the records provided, you have had difficulty with pain. The documentation shows that your 
provider would like to utilize psychological and neuropsychological testing to determine management of your 
pain and if you would be a suitable candidate for medication management. The medication was not mentioned 
and the type of treatment utilizing medication management was not outlined. Utilizing the criteria from LCD 
L34353 that this testing is intended to diagnose and characterize the neurocognitive effects of medical disorders 
that impinge directly on or indirectly on the brain including detection of neurologic disease based on 
quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic 
syndromes, delineation of neurocognitive effects of central nervous system disorders, neurocognitive 
monitoring of recovery or progression of central nervous system disorders or assessment of neurocognitive 
function for the formulation of rehabilitation and/or management strategies among individuals with 
neuropsychiatric disorders, you do not meet the criteria for psychological and neuropsychological testing as 
there is no documentation of the type of testing that is requesting, the type of treatment that is requesting and 
how the treatment would be different utilizing the information obtained from the testing. Neuropsychological 
and psychological testing is not considered reasonable or medically necessary for the treatment of your 
condition utilizing the information provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 23, 2020. 
 
You asked the Plan to pay for laboratory services. You say that based on the current federal guidelines for 
COVID-19 testing and reimbursement, the claim should be paid. 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 members terminal condition. 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. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has respiratory needs and 
comorbidities that cannot be met at a lower level of care. The Plan denied your request. The Plan says the 
medical record shows the enrollee does not meet Medicare guidelines for care in a LTACH. 
 
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 is currently undergoing treatment at an acute care hospital for 
pneumonia, in the setting of chronic respiratory disease. There is no evidence that the enrollee requires services 
that are not currently available. The enrollee can remain at the current acute care hospital facility until such 
time no acute services are required and then can be transferred/discharged to a lower level of care for any 
ongoing long term care needs. 
 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nursing service at home and physical therapy to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve nursing service at home and physical therapy to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
nursing service at home and physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia procedures provided on March 2, 2022. 
 
You asked the Plan to pay for anesthesia procedures. The Plan denied your request. The Plan says traditional 
Medicare would be the primary payer through the end of the month. 
 
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 March 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia 
procedures provided on March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary The Plan denied 
your request. The Plan says there is no trial of Holter monitor. 
 
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 ILR. Our physician reviewer found at this time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollee's 
clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).