Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the enrollee has received corticosteroid injections in 
the left knee since November of 2021, but that they are no longer providing any sense of relief. You say that 
the enrollee has had arthritis in her knees for a long time, has been working on home exercises, and has 
attempted use of anti-inflammatories for greater than 3 months. You say that there are arthritic changes on 
exam with no signs of inflammatory arthropathy. You say that there is x-ray evidence of degenerative joint disease. You say that the clinical information provided supports the need for Monovisc injection. The Plan 
denied your request. The Plan says there is no documentation that the preferred medication has been tried and 
failed or had an adverse reaction. 
 
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 Monovisc. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has received corticosteroid 
injections in the left knee since November of 2021, that are no longer providing any sense of pain relief. The 
enrollee has not trialed one preferred viscosupplemental treatment such as Orthovisc, Synvisc, or Synvisc-One. 
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 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cuvitru. 
 
You asked the Plan to pre-approve Cuvitru. You say that the requested Cuvitru is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Flebogamma DIF, Gammagard, 
Gammagard S/D, Gammaked, Gamunex-C, Hizentra, Octagam, Privigen, and Xembify first. 
 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 Cuvitru. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia. 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. 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. The requested service cannot be 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 Cuvitru have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cuvitru.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and need rehab and you cant get out 
of bed or do daily activities by yourself. The Plan denied your request. The Plan says the criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met. Your ongoing skilled therapy and nursing 
needs can be provided 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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on December 22, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you would like to be reimbursed 
for these test kits. The Plan denied your request. The Plan says these kits were purchased prior to the Plan's 
supplemental benefit for at-home COVID-19 test kits going into place. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits is an OTC item. The Plans contract states that they provide coverage for at-home COVID-
19 test kits purchased on or after February 1, 2022. The tests in question were purchased before this date. 
Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on 
December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequencing testing service provided on 
April 14, 2022. 
 
You asked the Plan to pay for the next generation sequencing testing service. You say that you would like this 
claim reprocessed for medical necessity. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing requires that the 
patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case, the enrollee has not been diagnosed with recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the next generation sequencing testing service have not been met. Therefore, we 
decided that the Plan does not have to pay for the next generation sequencing testing service provided on April 
14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 the medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. The requested service cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that the 
coverage criteria has not been met. 
 
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 the medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that you depend on this transportation to get 
to your appointments. The Plan denied your request. The Plan says your benefit covers a maximum of 50 
transportation trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips for 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs rehab says they need 
help with their breathing. The Plan denied your request. The Plan says the request is not medically necessary, 
when the enrollee is ready to leave the hospital, they can safely receive this care in another 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 transfer to the LTACH is not medically necessary as the patient would not likely 
improve with this transfer. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that skilled nursing facility care will not give the enrollee 
the best opportunity to regain baseline quality of life. The enrollee is clinically stable to discharge to a 
rehabilitation level of care. The Plan denied your request. The Plan says admission to the IRF was denied as not 
meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing 
facility level of care was offered. 
 
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 was admitted to an acute hospital on October 13, 2022, with acute 
hypercapnic respiratory failure, nausea, vomiting, diarrhea, and back pain. The enrollee was found to have 
severe sepsis from pyelonephritis and gram-negative bacteremia. The enrollee is medically stable and has 
improved clinically. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Their needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Compleat liquid nutritional supplements. 
 
You asked the Plan to pre-approve nutritional supplements. You say that you have lost a significant amount of 
weight and your provider recommended this supplement to help rebuild muscle and gain weight. The Plan 
denied your request. The Plan says nutritional supplements are not covered by your Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Compleat liquid nutritional supplements.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to make additional payment for the psychiatric evaluation provided on October 
27, 2021, billed with code 90791. We decided that the Plan does not have to make additional payment for the 
other services at issue, including codes 90875 and A9152.  
 
You asked the Plan to make additional payment for the medical and psychological services provided from 
August 3, 2020, through December 7, 2021. You say that you feel these services should be paid because you 
are not able to continue seeing this provider until the balance is paid off. The Plan says that the coverable 
services were reimbursed based on the Medicare allowable rate. However, 90971 was not billed with a valid 
diagnosis code, and A9152 and 90785 are not covered by Medicare. 
 
We decided that the Plan has to make additional payment for the psychiatric evaluation provided on 
October 27, 2021, billed with code 90791.  
 
The Plan follows Medicare rules. Medicare plans must make reasonable and diligent efforts to gather and 
forward information to the Independent Review Entity (IRE). 
 
In this case, a valid denial rationale was not submitted for code 90791. The Plan cited a Medicare coverage 
article A56937 to indicate that a valid diagnosis was not reported. This article is not applicable to your state. 
Without a valid rationale, we find that the Plan must pay the Medicare allowed amount for this service. 
Therefore, we decided that the Plan has to make additional payment for the psychiatric evaluation provided on 
October 27, 2021, billed with code 90791.  
 
We also decided that the Plan does not have to make additional payment for the other services at issue, 
including codes 90875 and A9152. 
 
The rules say that Medicare health plans are only required to pay up to the Medicare-allowed amount for 
covered services. Only Medicare-enrolled providers are required to accept this as payment in full. Nutritional 
supplements are also noted to be noncovered. 
 
Review of the file shows that the Plan provided reimbursement for covered services at the Medicare-allowed 
amount, less your contractual cost sharing. The Plan cannot be obligated to pay more for these services. In 
regard to code 90875, this code is listed as noncovered by Medicare in the Physician Fee Schedule, meaning no 
payment can be made for this code. In addition, code A9152 are for oral vitamins which cannot be covered by 
Medicare. No additional payment is required for these services. Therefore, we decided that the Plan does not 
have to make additional payment for the other services at issue, including codes 90875 and A9152. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been 
met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no 
additional services. 
 
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 requested treatments are not medically necessary at the LTACH level of 
care.  The enrollee has improved medically and can receive further care at the current acute care hospital or a 
lower level of care when deemed appropriate. 
 
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 LTACH services.
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 this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the criteria for admission to SNF have not been met. Skilled services 
can be provided on an intermittent outpatient basis, in a long-term care facility, or at the home with home 
health care services. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.