Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve physical therapy by an OON provider. You say that the enrollee says they 
have to go to an OON provider because they cannot find an in-network provider. 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 
physical therapy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for maxillary and mandibular complete 
dentures provided on August 26, 2022. 
 
You asked the Plan to waive the coinsurance for dentures. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for complete dentures.  
 
You have been asked to pay $929 which is 50% coinsurance for dentures. This item/service falls within the 
Dental Services 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 coinsurance for maxillary and mandibular 
complete dentures provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine thyroid uptake measurement. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a 
different scan is appropriate 
 
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 requested services. Our physician 
reviewer found that you have a thyroid nodule shown by imaging. The record indicates that a thyroid scan was 
intended to be ordered. The record provided does not establish the medical necessity and reasonableness of the 
requested service as ordered. The elements of the coverage criteria are not satisfied. The requested service 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nuclear medicine thyroid uptake measurement.
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 need intense rehabilitation. The Plan denied 
your request. The Plan says that the 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 that the documentation does not support necessity for admission to an IRF and the 
complexity of the enrollee's nursing, rehabilitation, and medical needs. You do not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While you may benefit from physical therapy, and occupational therapy, the enrollee's rehabilitation needs can be provided in a lower 
intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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: 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 will benefit from inpatient rehabilitation. 
The Plan denied your request. The Plan says the enrollee could receive care in an alternate level. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
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 the LTACH can render the specialized 
services that the enrollee needs. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital and is receiving the critical care that they 
need at the current 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 is currently undergoing treatment at an acute care hospital (ACH) 
following surgery for a bowel obstruction likely due to recurrent cancer. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary 
approach to daily therapy. 
 
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 clinical documentation shows that the enrollee has complex functional 
impairments (hip fracture IRF compliant) however no active medical comorbidities have been specified (HTN-
home meds resumed) thus the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 IRF admission and 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. You say that the enrollee had a leg amputation and 
needs this additional care. 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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. 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 he is not currently 
receiving but that would be available at the LTACH 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve . 
 
You asked the Plan to pre-approve a home ventilator. You say that you need a home ventilator prior to 
discharge. The Plan denied your request. The Plan says the needs can be met with a BiPAP device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our physician 
reviewer found that you have chronic respiratory failure from obstructive sleep apnea syndrome. The record 
does not indicate that you have restrictive thoracic disease. Notwithstanding that the noted indication is not one 
for which coverage is enumerated in the coverage criteria, the record indicates that you were successfully 
treated with CPAP. The provided documentation does not contain sufficient detailed information to justify the 
treatment selected. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve .
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 services are necessary to provide 
vent weaning and daily multi-specialty physician intervention and monitoring. The Plan denied your request. 
The Plan says the enrollee's condition is not stable for them to be moved until completion of their hospital 
course. 
 
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 in this case the enrollee was admitted following cardiac arrest and has an anoxic 
brain injury. The record indicates that the enrollee has ongoing acute critical care issues and still requires acute 
care services. 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 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 long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred step therapy drugs. 
 
 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 Trivisc. Our physician reviewer found 
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial 
of Orthovisc or Supartz FX before they will approve the requested drug. 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. Therefore, 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 Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Euflexxa (J7323). 
 
You asked the Plan to pre-approve the Euflexxa. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy requirements 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 the Euflexxa. Our reviewer says that 
this drug is not medically necessary. Our physician reviewer found 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. 
 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft procedure during approved lumbar surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
bone graft is not safe or helpful. 
 
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 requested services. Our physician 
reviewer found that osteopromotive allograft is not medically needed for this routine case of lumbar fusion. 
Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft procedure during approved lumbar surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on October 12, 
2022, through October 27, 2022 
 
You asked the Plan to pay for the outpatient hospital services. You say that the claim should be paid. The Plan 
denied your request. The Plan says the claim was not billed according to Medicare guidelines. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the outpatient hospital services have not been met. Providers have 
to bill accordingly with Medicare guidelines. This claim has not been billed accordingly with the Medicare 
guidelines. CPT code 22558 billed on October 25, 2022, was denied, as the code is an inpatient procedure code 
as per status indicator C and is incorrectly billed on an outpatient claim. It is not appropriate to bill an 
inpatient only procedure on an outpatient hospital claim. The rules says that Centers for Medicare & Medicaid 
Services (CMS) does not pay for an "inpatient-only" service furnished to a person who is registered in the 
hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does 
not pay for all other services on the same day as the "inpatient only" procedure. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services provided on October 12, 2022, through October 
27, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says the documentation does not meet the criteria. 
 
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 requested services. Our physician 
reviewer found that there is no evidence of lumbar instability, fracture, or lesion on imaging studies. Fusion for 
degenerative back pain is experimental. Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
available data is inconsistent and without long-term benefits. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. He has a past medical history of Rheumatoid 
arthritis. The requested service is considered experimental/investigational because of the wide variation in 
efficacy reported in the literature. Therefore, the request is deemed not medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.