Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractor services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractor services. You say that it is medically necessary for the enrollee 
to receive this care from an OON provider. The Plan denied your request. The Plan says there are multiple in-
network options for the enrollee to receive this medical care. 
 
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 
chiropractor services to be provided 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 echocardiography (99306) and perflutren lipid 
microspheres injection (Q9957) provided on August 31, 2020. 
 
You asked the Plan to pay for the echocardiography and perflutren lipid microspheres injection. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the corrected claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the echocardiography and perflutren lipid microspheres injection was not 
filed until October 26, 2021. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for the echocardiography 
(99306) and perflutren lipid microspheres injection (Q9957) provided on August 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inflammatory bowel disease serologies. 
 
You asked the Plan to pre-approve the inflammatory bowel disease serologies. You say that the enrollee has 
very refractory Inflammatory Bowel Disease (IBD) and a very distant diagnosis of Crohns disease. You also 
say that you do not see any small bowel involvement and you may be looking at surgical resection which 
would be impacted by the enrollees diagnosis of Crohns versus Ulcerative Colitis while the serologies are not 
diagnostic alone in combination with other clinical factors, it can help support the distinguishing diagnosis. The 
Plan denied your request. The Plan says there is insufficient evidence of efficacy for the use of this type of 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that evidence is insufficient to support an indirect 
chain of evidence for clinical utility due to lack of details about study methodology and lack of replication of 
the findings.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inflammatory bowel disease serologies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the inflammatory bowel disease serologies.
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 is the most appropriate setting for this patient. 
The Plan denied your request. The Plan says IRF admission is not medically necessary and the patient can be 
managed 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for nausea and ataxia and their medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for non-surgical management of a pelvic fracture after a fall. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a Prolia (denosumab) injection provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you were not aware there was a 
copayment you would be responsible. The Plan denied your request. The Plan says that you have been charged 
the correct cost sharing amount. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the explanation of benefits (EOB) for the injection. 
Without the EOB we are unable to determine if the cost sharing applied is correct. Therefore, we decided that 
the Plan has to waive the copayment for a Prolia (denosumab) injection provided on February 22, 2022. 
  
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
volume overload, respiratory failure, and pneumonia. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Feraheme. There 
is no indication that the enrollee has tried and failed the required drugs or that the Plan's 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary denture (D5130) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve an immediate maxillary denture. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the benefit limit for D5130 has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers an immediate 
maxillary denture once a lifetime.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D5130 was provided on May 21, 
2021. Based on this information, we decided that the Plan's rules for coverage of an immediate maxillary 
denture have not been met. Therefore, we decided that the Plan does not have to pre-approve an immediate 
maxillary denture (D5130) to be provided by a participating 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 you want to be transferred to LTACH for 
a higher level of care instead of SNF. The Plan denied your request. The Plan says authorization denied 
because LTACH is not medically necessary and your needs can be met at a lower level of care such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at 
the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
in the setting of cirrhosis. He has not tried and failed the Plan's required drugs, Infed and Venofer. The records 
do not show that the required drugs would be contraindicated or less effective; therefore, the Prolia is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve laboratory testing services. You say that this care is medically necessary. 
The Plan denied your request. The Plan says there are in-network options available. 
 
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 
laboratory testing services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on May 1, 2022 with congestive heart failure and right greater than left pleural effusions. She had occupational 
therapy in the hospital and needs stand by assist for at-sink handwashing and functional ambulation. She has no 
skilled nursing needs. She does not require skilled therapy on a daily basis. As a practical matter, the enrollee 
does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony (D7240 x 
2). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford the cost of these 
services. You say that you are on a very limited income. You also say that you would like these services to be 
covered. The Plan denied your request. The Plan says that removal of impacted tooth is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of impacted 
teeth are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve removal of impacted tooth - completely bony (D7240 x 2).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for non ST elevation myocardial infarction. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Daliresp for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication falls under Part D coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Daliresp for the enrollee.