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

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been 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 Euflexxa. Our reviewer says that this 
drug is not medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 77 
year old female with osteoathtritis of the knee. Her provider has recommended visco-supplementation therapy 
with Euflexxa. The enrollee has not trialed one of the preferred viscosupplemental treatments such as, 
Orthovisc or Supartz FX. Step therapy, as outlined by the Plan, requires that one of these be trialed first. The 
documentation does not outline contraindications or reasons these medications were not considered or that the 
plans additional required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Without the support of the documentation, Euflexxa is not approved as step criteria has 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
 
 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 laboratory 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 the laboratory services provided on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care billed for services provided on October 30, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the code remains not supported. 
 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. Critical care is the direct delivery by a physician(s) 
or other qualified healthcare professional (QHP) of medical care for the critically ill/injured in which there is 
acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-
threatening deterioration of the enrollees condition. We find that CPT code 99291 is not supported in the 
medical record. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care billed for services provided on 
October 30, 2021.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says records show its not medically safe for you to go to an LTACH. 
When you are ready to leave the hospital, you can safely receive care in another setting such as in an inpatient 
rehab facility or in a skilled nursing facility. 
 
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 that there are no services at the LTACH that you require 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on January 17, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 Domiciliary services 
provided on January 17, 2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health provided on November 5, 2021 to 
December 3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health. You say that you would like to request reconsideration 
of the denied claim and that your PCP made a referral. The Plan denied your request. The Plan says after a 
review it has been determined the claims processed correctly. The rendering provider is non-par and there isn't 
a referring 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 Outpatient Mental Health provided on November 
5, 2021 to December 3, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have a right to recover outside a contract for 
any service you provide to the enrollee. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 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 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. The records 
provided for review do not show that the office visit was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on January 3, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on June 29, 2021, to July 
7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the facility was unable to verify their 
insurance. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
inpatient hospital care. We found no exception that would require the Plan to pay for the inpatient hospital care. 
The records provided for review do not show that the inpatient hospital care was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided on June 29, 
2021, to July 7, 2021, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 you do 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 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 IRF care is medically necessary as it will optimize 
the enrollee's level of functioning prior to returning home. The Plan denied your request. The Plan says IRF 
care is not medically necessary and while the enrollee would likely benefit from ongoing therapy there is no 
evidence that it cannot be safely done at a lower level of 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 that while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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 pay for Outpatient Surgery provided on January 10, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Surgery. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says this isn't covered. Your plan excludes coverage for this 
out-of-network service. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 Outpatient Surgery provided on January 10, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing this claim. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 28, 2021, by an 
out-of-network (OON) provider.
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 the enrollee appears to be unstable and requires additional short-term acute care 
services that can be safely administered at the current facility until more stable and appropriate for 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wellness visit provided on December 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wellness visit. You say that you would like reconsideration of the denial and 
for the services to be approved. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 a wellness visit provided on December 30, 2021, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2001). 
 
You asked the Plan to pre-approve routine transportation. You say that you need transportation to and from 
your doctor visits. You say that you are not able to drive due to your medical issues. You also say that this 
should be covered. The Plan denied your request. The Plan says routine transportation is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation (T2001).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional level, you need to continue home rehab and do not require 3 hours a day, 
five days a week of IRF therapies with interdisciplinary management. Your rehab needs can be provided in an 
alternate and low intensity setting such as in a skilled nursing facility if continuation of therapies is not viable. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on February 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing was reasonable and necessary for 
the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says that there was 
an invalid combination of modifiers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The services at issue were denied due to an invalid combination of 
modifiers. However, the claim provided does not show that the services were billed with modifiers. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the lab services provided on February 15, 
2021.  
 
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.