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 you would like reconsideration because the IRF care 
is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for IRF 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. 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. There is no documentation of a need for an intensive rehabilitation 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. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy (OT) evaluation 
provided on October 13, 2021. 
 
You asked the Plan to waive the copayment for an OT evaluation. You say that you were not told in advance 
about a copayment. You also say that the provider only downloaded an app and collected medication 
information. The Plan denied your request. The Plan says you have been charged with the cost sharing amount. 
 
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 $40 
copayment for in-network outpatient rehabilitation services, including occupational therapy.  
 
 The medical record shows that the occupational therapist spent two hours at your home doing your evaluation 
on October 13, 2021. You have been asked to pay a $40 copayment for an OT evaluation. An OT evaluation 
falls within the Outpatient Rehabilitation 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 occupational therapy (OT) evaluation provided on October 13, 2021.  
 
Your complaint about not being told in advance about a copayment and the therapist not going over safety 
issues is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested drug is necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs. 
 
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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria have not been 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, fluorescence in-situ hybridization (FISH) testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Velcade. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple myeloma. She 
has not tried and failed the Plan's required drug, bortezomib. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Velcade is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Velcade.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has overactive bladder and 
has improved on Mybertriq. There is no documentation of an inadequate response or intolerance to 
anticholinergic medications. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for the enrollee's condition and the use is not supported in the Medicare-approved drug compendia. 
The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has psoriatic arthritis. She 
has not tried and failed the Plan's required drugs, Xeljanz or Xeljanz XR. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Simponi Aria is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a hearing exam provided on November 16, 
2021. 
 
You asked the Plan to reduce the copayment for a hearing exam. You say that you paid a $25 copayment as 
stated by the receptionist at the providers office. You also say that you received a bill for a $35 copayment, and 
that same day you went into the hospital to pay it. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $35 
copayment for a diagnostic hearing exam with a specialist.  
 
You have been asked to pay a $35 copayment for a hearing exam. A hearing exam falls within the Hearing 
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 reduce the copayment for a hearing exam provided 
on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from May 17, 2020, to May 22, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that the diagnosis code is 
supported. The Plan denied your request. The Plan says the principal diagnosis code, A41.51, sepsis due to 
Escherichia coli, is not supported. 
 
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 principal diagnosis code, A41.51, sepsis due to 
Escherichia coli. 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 an additional amount for the 
inpatient care. Our reviewer says that the billing of the principal diagnosis code, A41.51, sepsis due to 
Escherichia coli is not supported. Our physician reviewer found the provided documentation does not indicate 
there was a clinical or laboratory evidence of sepsis. Therefore, the reviewer has determined that the provided 
documentation did not support the billing of principal diagnosis code, A41.51, sepsis due to Escherichia coli.  
 
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 
an additional amount for the acute inpatient hospital care provided from May 17, 2020, to May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fluoroscopic guided lumbar epidural 
injection provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for a lumbar epidural injection. You say that the service was just 
an injection not a surgery. You also say that the doctor billed the wrong code. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $100 
copayment for outpatient procedures and services, including outpatient surgery at an outpatient hospital. 
 
 The record shows a lumbar epidural injection is considered a surgical procedure. You have been asked to pay a 
$100 copayment for a lumbar epidural injection. A lumbar epidural injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a fluoroscopic guided lumbar epidural injection 
provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), expandable 
controller harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller, harness and electronic connection. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
there is not a medical need to control these power options through the joystick. 
 
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 expandable controller, harness and 
electronic connection. Our reviewer says that the expandable controller, harness and electronic connectionare 
not medically necessary per the Local Coverage Article. Our physician reviewer found the enrollee has 3 power 
options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options 
through a joystick. The enrollee's upper extremity strength  supports that the enrollee can control any power 
options through their own switches. 
 
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 expandable controller, harness and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), 
expandable controller harness (E2313) and electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on November 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the skills of the therapist may not necessarily be required. 
 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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
there are no documented ongoing home health physical therapy needs. The enrollee is functioning at a level 
commensurate with a lower level of care, such as a home exercise program or outpatient therapy. As such, the 
ongoing home health physical therapy services are 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy visits for the enrollee.
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 would like reconsideration because the IRF care 
is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of 
IRF 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is no documentation of 
a need for an intensive rehabilitation 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. 
 
 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care to return to normal daily living 
activities. The Plan denied your request. The Plan says you do not meet Medicare criteria for admission to an 
IRF. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation 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. 
 
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 Enbrel. 
 
You asked the Plan to pre-approve Enbrel. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 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 pre-approve Enbrel.  
 Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.