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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 the 
complexity of the patient's nursing, medical and rehabilitation needs did not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care.  The patient did not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Medicare coverage 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met.  
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the records show the enrollee appears to 
have plateaued. The documentation does not support that it is medically reasonable and necessary to provide 
ongoing skilled services on a "daily basis" on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F1Heme testing (81455) provided on August 11, 2021. 
 
You asked the Plan to pay for the F1Heme testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the F1Heme testing (81455) provided 
on August 11, 2021. have been met. 
 Specifically, the documentation submitted does not include any clinical information to verify why this testing 
was ordered, support medical necessity or validate how this testing will affect the enrollee's treatment. 
Therefore, we decided that the Plan does not have to pay for the F1Heme testing (81455) provided on August 
11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fosaprepitant (J1453) and Aloxi (J2469). 
 You asked the Plan to pre-approve Fosaprepitant and Aloxi. You say that the enrollee is receiving these 
enemetic drugs with chemotherapy. You also say that the enrollee is in a clinical trial and this is a continuation 
of treatment which she was approved for previously. The Plan denied your request. The Plan says the 
information says the enrollee is in a clinical trial. The Plan also says that services related to clinical trials 
cannot be pre-approved. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Fosaprepitant and Aloxi as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Fosaprepitant (J1453) and Aloxi (J2469).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is still in need of complex 
wound care management and long-term IV antibiotics which cannot be met at a lower level of care. The 
treating physician states the LTACH is in the enrollee's best interest in order to achieve positive outcomes. The 
Plan denied your request. The Plan says authorization denied because LTACH is not medically necessary and 
the enrollee's needs can be met at a lower level of care, such as a skilled nursing facility, home with home 
health services, or outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation showed that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. 
 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: 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 you strongly recommend that LTACH is 
the most appropriate level of care for the enrollee, based on the enrollee's condition. The Plan denied your 
request. The Plan says authorization denied because the LTACH is not medically necessary, and the enrollee 
can stay at the current acute care location until no further acute level care is needed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. 
 
 
 
 
  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015), provided on 
October 13, 2021. 
 
You asked the Plan to pay for the eye exam and refraction. You say that the services should be covered. The 
Plan denied your request. The Plan says these are not covered benefits. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015), provided on 
October 13, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tepezza (teprotumumab). 
 
You asked the Plan to pre-approve Tepezza. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says that there is not enough evidence to prove that using more than 8 doses of 
Tepezza will improve health outcomes. 
 
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 Tepezza. Our reviewer says that the 
coverage criteria for Tepezza has been met. Our physician reviewer found the record indicates that the enrollee 
has previously been successfully treated with the requested agent and completed a course of therapy in 
approximately October 2021. The reviewer found that the enrollee now has recurrent symptoms. The reviewer 
found that the Food and Drug Administration (FDA) has stated that the requested drug is indicated for the 
enrollee's condition. The FDA has not stated that subsequent courses of therapy are not indicated. Therefore, 
the reviewer found that the coverage criteria for the requested drug has 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 Tepezza have been met. Specifically, the record shows that the Food and Drug 
Administration has not stated that subsequent courses of the requested therapy are not indicated. Therefore, we 
decided that the Plan has to pre-approve Tepezza (teprotumumab).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care as of 
March 16, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued SNF care is medically 
necessary. The Plan denied your request. The Plan says SNF care is not medically necessary as of March 16, 
2022. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found he enrollee no longer qualifies for 
SNF coverage.  The enrollee does not have documented skilled nursing needs.  The enrollee does not have 
documented skilled therapy needs.  The enrollee is ambulating 100 feet.  Daily skilled services are not required 
to establish a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care as of March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT) 
monitoring. 
 
You asked the Plan to pre-approve MCOT monitoring. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not meet the coverage criteria. 
 
The Plan follows Medicare rules Medicare rules state that cardiac event detection tests may be covered if 
certain 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 MCOT monitoring. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested MCOT monitoring. Our physician 
reviewer found the enrollee has palpitations. There is no supporting evidence that the ordering practitioner 
documented any standard, non-MCOT, ambulatory electrocardiogram monitoring. In summary, there is 
insufficient documentation to support the medical necessity for an MCOT monitor at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MCOT monitoring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitoring.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after 
March 16, 2022. 
 
You asked the Plan to pre-approve the SNF services. You say that continued SNF care is medically necessary. 
The Plan denied your request. The Plan says you no longer require SNF services after March 16, 2022. 
 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF 
coverage.  You do not have documented skilled nursing needs or skilled therapy needs.  You appear to have 
reached a plateau in function.  Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition.  Your care needs, custodial and intermittent, can, as a practical matter, 
be provided 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services after March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the peri-implant capsulectomy (19371) provided on May 13, 
2021. 
You asked the Plan to pay for the peri-implant capsulectomy (19371). The Plan denied your request. The Plan 
says an appropriate modifier was not billed with this code edit. 
 
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 19371 
is a column II code to column I code 19342. 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 peri-implant capsulectomy (19371) provided on May 13, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310) and crown repair necessitated by 
restorative material failure (D2980). 
 
You asked the Plan to pre-approve the consultation and crown repair. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
consultation (D9310) and crown repair necessitated by restorative material failure (D2980).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that you believe that because you do not have a contract 
with the Plan, that these services should be paid. The Plan denied your request. The Plan says the lab services 
are not separately payable because the enrollee is an end stage renal disease patient and is on dialysis. 
 
The Plan must follow Medicare rules. Medicare rules say that for end-stage renal disease (ESRD) patients on 
dialysis, lab services are generally included in the ESRD prospective payment system (PPS) rate and are not 
separately payable.  However, if the lab service is a test that is not related to ESRD, the entity may separately 
bill for that test using the AY modifier.  In this case, the enrollee is an ESRD patient on dialysis.  You 
performed lab services for the enrollee, but you did not append the AY modifier to the claim for these services.  
This means that the lab services are included in the ESRD PPS payment and are not separately payable. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were provided in good faith and 
should be covered. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. There is no evidence that a Plan provider requested these services. We found no exception 
that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to 
pay for lab services provided on October 12, 2021, by an out-of-network (OON) provider.