Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you will be having a full knee 
replacement, and need to stay at the hospital to make sure that you will be getting proper medical attention if 
needed. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
received, the enrollee's care could be provided without an inpatient stay after the surgical procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient pre-approval are met in this 
case. Our physician reviewer found there are no noted conditions which would be expected to extend the length 
of medically necessary hospital care. Our physician reviewer also found that the record does not show that at 
the time of inpatient admission, the admitting physician reasonably expects that the patient's necessary hospital 
care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
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 the enrollee meets Medicare criteria for admission 
and rehabilitation cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
the enrollee may be eligible for a lower level of care, such as a skilled nursing unit, skilled nursing facility, an 
outpatient rehabilitation facility, or at home with home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for a seizure, altered mental status and respiratory 
failure. Medical problems are stable. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compressor and segmental pneumatic appliance. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the service can be provided 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 
pneumatic compressor and segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device and segmental appliance 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device and segmental appliance. You say that the 
device is necessary for your therapy. The Plan denied your request. The Plan says the service can be provided 
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 
pneumatic compression device and segmental appliance to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have multiple conditions that need 
daily complex care by a physician. The enrollee does not need daily complex wound care or frequent dressing 
changes. Based on the enrollee's medical condition and treatments, the enrollee will not need this level of 
service for 25 or more days. The level of care provided in the LTACH setting is more than the enrollee's 
medical conditions needs. The enrollee needs can be met at an alternate level of care like 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 in this case the enrollee was admitted with acute on chronic respiratory failure in 
the setting of idiopathic pulmonary fibrosis. The record indicates that the enrollee is improving but still require 
acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care 
services, and these have not been denied. 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. 
 
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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage 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 Leqvio. Our reviewer says that the 
requirements for coverage of Leqvio have not been met. Our physician reviewer found the Plan requires a trial 
of a PCSK9 inhibitor drug like Repatha and one high-intensity statin drug in addition to ezetimibe for at least 8 
weeks before they will approve the requested drug, Leqvio. There is no indication that the patient has tried and 
failed these drugs or that these drugs would likely be less effective or have adverse effects. While the records 
document the enrollee was enrolled in a study of Leqvio, there are no details of the dosing schedule, use of 
other medications in the study, or use of placebo in the study provided to clarify that the Leqvio meets step 
therapy or prior authorization criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for an inpatient hospital stay.. We decided that the Plan 
does not have to waive the copayment for an outpatient hospital observation stay.  
 You asked the Plan to waive the copayment for an outpatient hospital observation stay provided from May 12, 
2022, to May 24, 2022. You say that these are very expensive, and often lifesaving, treatments needed to keep 
you alive until your liver transplant. The Plan says that the copayment applied is correct. 
 
We decided that the Plan has to waive the copayment for an inpatient hospital stay..  
 
The Plan follows Medicare rules. Medicare rules say that a Plan must disclose to its enrollees in clear, accurate 
terms all cost-sharing information (such as copayments, coinsurance, and deductibles). Your contract with the 
Plan clearly says that you must pay a $275 copayment per visit for Medicare-covered outpatient hospital 
observation services. Although the Plan claims this was an inpatient hospital stay and were charged for two 
days at $275 per day, the information provided shows this was an outpatient hospital observation stay. 
Therefore, you can only be charged a $275 copayment per visit. 
 
The Plan says that you must pay a total amount of $550 copayment. Based on your contract with the Plan, 
however, you cannot be asked to pay more than $275 for this outpatient stay. Therefore, we decided that the 
Plan has to reduce your total copayment amount from $550 to $275.  
 
 
We also decided that the Plan does not have to waive the copayment for an outpatient hospital 
observation stay. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per visit for an outpatient hospital observation stay. Therefore, we decided that the Plan does not 
have to waive the copayment for an outpatient hospital observation stay. 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that physical therapy is necessary and is working for the 
enrollee. The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation 
facility services you are requesting do not meet the requirements for approval. 
 
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 for sepsis, urinary tract infection, and kidney stone. 
Medical problems are stable. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for intravenous infusions provided January 3, 
2022, to January 7, 2022. 
 
You asked the Plan to reduce the coinsurance for intravenous infusions. You say that the Explanation of 
Benefits (EOB) indicates the claim processed as out-of-network. The Plan denied your request. The Plan says 
the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for drugs that usually aren't self-administered by the patient and are injected or infused while you 
are getting in-network physician, hospital outpatient or ambulatory surgical center services.  
You have been asked to pay a 20% coinsurance for intravenous infusions. Intravenous infusions fall Medicare 
Part B Prescription Drugs benefit category. Please note: the out-of-network cost share for intravenous infusion 
is also a 20% coinsurance. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for intravenous infusions 
provided January 3, 2022, to January 7, 2022.  
 
Date of Service Amount 
Submitted 
Plan Allowance Plan Paid Coinsurance 
1/3/22 $521.00 $202.09 $161.67 $40.42 
1/4/22 $521.00 $202.09 $161.67 $40.42 
1/4/22 $98.00 $39.53 $31.62 $7.91 
1/5/22 $521.00 $202.09 $161.67 $40.42 
1/5/2022 $98.00 $39.53 $31.62 $7.91 
1/6/2022 $521.00 $202.09 $161.67 $40.42 
1/7/2022 $521.00 $202.09 $161.67 $40.42 
Total $2801.00 $1089.51 $871.59 $217.92
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat treatment with Tepezza (J3241). 
 
You asked the Plan to pre-approve Tepezza. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical-necessity rules have not been met because 
the requested drug is prescribed for an off-label and not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of severe recurrent thyroid eye disease. The FDA has stated that the requested drug is 
indicated for the enrollee's condition. The FDA label does not limit the treatment to one course. 
 
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. Therefore, we decided that the Plan has to pre-approve 
a repeat treatment with Tepezza (J3241).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
June 7, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not be 
responsible to pay this because this was a routine/preventative colonoscopy. The Plan denied your request. The 
Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery performed at a freestanding ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for a diagnostic colonoscopy. Records submitted support a 
diagnostic colonoscopy was provided. A diagnostic colonoscopy falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on June 7, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive the LTACH services. The Plan denied your request. The Plan says the records do not show that the 
enrollee's condition will require an average 25-day length of stay in the LTACH. When the enrollee is ready to 
leave the hospital, they can safely receive this care in another setting like 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve steroid injections to the lower back (64483, 64494, 
64493). 
 
You asked the Plan to pre-approve the injections. You say that please re-review for authorization as you are 
appealing the denial. The Plan denied your request. The Plan says the records do not document as to why 
radiofrequency ablation has not been tried first. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. The enrollee has had epidural steroid injections and 
several facet injections but not radiofrequency ablation. The standard of care is diagnostic medial branch 
blocks and then radiofrequency ablation, it is not a series of facet injections. The request is considered not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve steroid injections to the lower back (64483, 64494, 64493).