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

 
We decided that the Plan does not have to pre-approve Cimzia (certolizumab pegol) treatments. 
 
You asked the Plan to pre-approve the Cimzia treatments. You say that it is felt this medication is necessary. 
The Plan denied your request. The Plan says step therapy requires a trial of other drugs prior to approving 
Cimzia. 
 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 Cimzia treatments. Our reviewer 
says that the requested medication is not considered reasonable and necessary based on step therapy criteria. 
Our physician reviewer found the record indicates that the enrollee has rheumatoid arthritis.  The requested 
medication is a new start.  The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative, such as an infliximab biosimilar (Avsola, Inflectra, Renflexis) and Simponi Aria. 
The record does not provide a sufficient medical rationale why the plan's alternative tumor necrosis factor 
(TNF) inhibitor is not appropriate for the enrollee's specific clinical condition. 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. The elements of the coverage criteria are not satisfied.  
 
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 Cimzia treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Cimzia (certolizumab pegol) treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist. 
 
You asked the Plan to pre-approve these services. You say that the provider is closer to your daughter's 
residence. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network oncologist.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is now able to work well with 
physical therapy. The Plan denied your request. The Plan says the enrollee does not require daily skilled 
services as an inpatient. 
 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 physician reviewer 
found that the enrollee presented to the acute hospital with acute on chronic respiratory failure with COVID-19 
infection. He allowed active and passive range of motion exercises in bed but not out of bed activities. He is 
reported to be total assist for transfers and activities of daily living. The records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care, or other skilled nursing 
services. The provided records do not document a significant decline in his functional status compared to his 
recent baseline to necessitate daily inpatient skilled therapy services. The records do not document the enrollee 
is willing and able to participate in daily therapy treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON second opinion. You say that the complexity of your problem and 
your age make you a high-risk surgical candidate. You say that the requested OON provider performs 
thousands of the needed procedure every year, whereas the contracted provider you were referred to only 
performs one a week. The Plan denied your request. The Plan says they have contracted providers who are 
accepting patients and have availability within two weeks. the Plan says that these network providers have the 
education, experience, and training to treat the enrollee's condition. 
 
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 OON second opinion. Our reviewer 
says that the criteria for OON care have not been met. Our physician reviewer found there are credentialed 
physicians within the enrollees network who are experienced in the placement of endovascular thoracic stents. 
There is insufficient documentation to support the medical necessity for referral to an out-of-network provider 
for the enrollees vascular treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OON second opinion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a second opinion with an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl (luspatercept-aamt) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested drug is not medically reasonable or necessary. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of an erythropoietin stimulating agent and at least two units of red blood cells in transfusion before they will 
approve the requested drug. In this case it was noted that member received treatment with Epoetin Alpha 
injection on 2/18/2022 and developed chest pain after infusion. There is documentation provided indicating that 
the plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl (luspatercept-aamt) for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for the hand brace. 
 
You asked the Plan to provide coverage for a hand brace. You say that the hand brace was recommended to use 
by your provider to avoid surgery. You say whenever you experience pain you can put the hand brace on, and it 
helps to stabilize your thumb and lessen your pain. The Plan denied your request. The Plan says over the 
counter DME items are excluded from coverage. 
 
The Plan contract says that over the counter DME items are excluded from coverage. 
 
We looked at the file and the Plans rules. The Plan says that over the counter DME items are excluded from 
coverage. Therefore, we decided that the Plan does not have to provide coverage for the hand brace.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar or sacral epidural injection, a shot of pain 
numbing substance into the lower back or tailbone spinal nerves using imaging guidance or detailed pictures 
(CPT code(s): 64484 and 64483). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found criteria for ESI not met. There is no leg pain and radiculopathy. 
 
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 lumbar or sacral epidural injection, a shot of pain numbing substance into the lower back 
or tailbone spinal nerves using imaging guidance or detailed pictures (CPT code(s): 64484 and 64483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
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. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (CPT code 99205) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan 
denied your request. The Plan says the services can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the 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 the office visit 
(CPT code 99205) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan 
denied your request. The Plan says the service can be received by an in-network provider. 
 
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 the MRI to be 
provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the 
services the enrollee requires can safely be received at a different setting, for example, home with home health, 
in residential care, or home with close follow-up with their doctor. 
 
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 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 household distances and practicing higher level activities of daily 
living (ADLs). The enrollees care needs can 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 reasonable and necessary for 
the enrollee's 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 the patient was admitted for surgical repair of an ankle fracture after a fall.  
 Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. In conclusion, 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the otoplasty (69300). 
 
You asked the Plan to pre-approve the otoplasty (69300). You say that you are not sleeping well because of the 
protrusion of your ears. You say that you already made arrangements for surgery, and you will forfeit the 
money you paid if you are not able to keep this date. The Plan denied your request. The Plan says cosmetic 
surgery is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic surgery and related services, except as 
required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, 
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 otoplasty (69300). Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have excess ear tissue and there is no indication of functional impairment. 
The requested procedure is considered cosmetic in nature and 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 otoplasty (69300) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the otoplasty (69300).  
 
Your complaint about being discriminated against due to your age 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). 
 
You asked the Plan to pre-approve the orthosis. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. There are not enough studies on MyoPro to show it to be safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the MyoPro myoelectric orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs admission to acute inpatient 
rehabilitation. The Plan denied your request. The Plan says authorization denied because the IRF is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
August 9, 2021. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation (90791). You say that you never visited this 
facility and never asked to be referred for a psychiatric diagnostic evaluation. You say that you never received 
any psychiatric care and want this resolved. The Plan denied your request. The Plan says manifestation codes 
cannot be billed as first listed diagnosis on claim. 
  The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
In this case, the CPT Code Manual definition of code 90791 is psychiatric diagnostic evaluation. 
 
We find that CPT code 90791 is not supported in the medical record. Specifically, the manifestation code 
cannot be listed as the primary diagnosis code. Based on this information, we decided that Medicare rules for 
coverage of the psychiatric diagnostic evaluation (90791) have not been met. Therefore, we decided that the 
Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on August 9, 2021.