Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have been educated on a home exercise program. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 received 5 home health physical therapy visits, and authorization for 8 additional 
physical therapy home visits are being requested. The clinical documentation does not state any unmet physical 
therapy goals. The documentation does states that you are ambulating 350 feet with a rolling walker and that a 
home exercise plan has been reviewed, thus a professional therapist would no longer be required. Therefore, 
the requested additional physical therapy sessions are not medically necessary based on clinical documentation. 
 
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 home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an interrogation device evaluation provided 
on January 27, 2022. 
 
You asked the Plan to waive the copayment for an interrogation device evaluation. You say that the proper 
copayment was not applied it should have been different. The Plan denied your request. The Plan says the 
proper copayment was applied for the service that was rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $50 copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
  The enrollee has been asked to pay a $50 copayment for an interrogation device evaluation. An interrogation 
device evaluation falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an interrogation device 
evaluation provided on January 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 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 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that you require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the home with home health care or in a long-term care facility 
on a part time basis are not appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone. 
 
You asked the Plan to pre-approve Dexamethasone. 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 Dexamethasone have not been met. Therefore, we decided that the Plan does not have to pre-
approve Dexamethasone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection of anesthetic agent and/or steroid (64450) billed 
for dates of service August 20, 2021, and August 27, 2021. 
 
You asked the Plan to pay for an anesthetic or steroid injection. You say that you have provided medical 
records to support the services billed. The Plan denied your request. The Plan says rules for payment have not 
been met because the service at issue is not separate and distinct. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 pay for an anesthetic or steroid injection Our 
reviewer says that the service at issue does not meet criteria for payment. Our physician reviewer found that the 
procedure report describes that injection was performed for anesthetic on August 20, 2021, and therefore would 
be included in the primary procedure. The available medical records do not include the procedure report for 
August 27, 2021, and therefore the services for August 27, 2021, cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an anesthetic or steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pay for an injection of anesthetic agent and/or steroid (64450) billed for dates of 
service August 20, 2021, and August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray (73502) provided on October 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the x-ray was medically necessary. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The referring provider is not a network 
provider either. The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hip x-ray (73502) provided on October 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for those patients who do not receive adequate relief from traditional conservative methods and 
who don't have instability to indicate fusion is the appropriate treatment. The Plan denied your request. The 
Plan says the requested service is considered experimental and investigational as it is not widely used or 
generally accepted for the suggested use as reported in nationally recognized peer-reviewed literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 you can't walk or go to the bathroom and want to go 
to this facility because it is closer to your residence. The Plan denied your request. The Plan says your records 
do not show that you are able to take part in 3 hours of therapy 5 days per week, nor do you need to 
be seen by a rehabilitation doctor 3 times per week. The services you need can be provided safely in other 
settings. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (11420) provided February 21, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 11420 is not supported in the medical record. Specifically, the operative report 
describes excision of left temple lesion performed for squamous cell carcinoma. In this case, there is a more 
appropriate code to report. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. 
 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for surgical services (11420) provided February 21, 
2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that records do not support the necessity of the intensity of service at an 
inpatient rehabilitation 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and a fall. Your 
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 the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation; taxi (A0100) provided on 
January 24, 2022. 
 
You asked the Plan to pay for the transportation service. You say that you are not happy with the plan's 
transportation vendor. You say that you would prefer to use someone else. You also say that the plan's 
transportation vendor does not treat the members right and drive smelly vehicles. The Plan denied your request. 
The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the transportation service have not been met. Therefore, we decided that 
the Plan does not have to pay for the non-emergency transportation; taxi (A0100) provided on January 24, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transport. 
 
You asked the Plan to pre-approve non-emergency ambulance transport. You say that you cannot afford 
transportation. The Plan denied your request. The Plan says the medical documentation received does not 
support this service because there is no medical need for you to require an ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport. 
Our reviewer says that non-emergency transportation is not medically reasonable and necessary. Our physician 
reviewer found that the documentation does not support that other means of transport (such as stretcher van, 
wheelchair van) are contraindicated for this enrollee. The documentation does not support that the enrollee 
needs the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance 
can provide for safe transport for this non-emergent scheduled visit. The documentation does not support that 
the requested ambulance transport is medically reasonable and necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transport have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a finger orthosis provided on November 
24, 2021. 
 
You asked the Plan to waive the coinsurance for the finger orthosis. You say that you should not have to pay 
for a finger bandage when the doctor could not fix the broken finger. The Plan denied your request. The Plan 
says the correct coinsurance was applied. 
 
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 each durable medical equipment (DME) item.  
 
You have been asked to pay $11.72, which is 20% of the allowed amount for the finger orthosis ($58.58 
allowed amount x 20% coinsurance = $11.72). The finger orthosis falls within the Durable Medical Equipment 
(DME) and Related Supplies 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 a finger 
orthosis provided on November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the provider does not want to use the bisphosphonate 
drugs because the enrollee has a recent history of surgery and an upcoming surgery, and these drugs do not 
allow for appropriate infusion of bones post-operatively. You say that the provider wants to use Evenity to 
improve and build (not just strengthen) the bones prior to the upcoming surgery. You say that the enrollee also has a history of GERD which is a contraindication to bisphosphonate. The Plan denied your request. The Plan 
says they require the enrollee try other drugs for her condition before Evenity will be covered. 
 
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 Evenity. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of an oral 
bisphosphonate and zoledronic acid or Prolia before they will approve the requested drug, Evenity.  Based on 
the medical records provided there is no indication that the patient has tried and failed the required drug(s). The 
enrollee has a history of gastroesophageal reflux which can be a contraindication to use of an oral 
bisphosphonate, but the records and the Medicare-approved major drug compendia do not support that 
zoledronic acid or Prolia would likely be less effective and/or likely have adverse effects for the enrollee. The 
Medicare-approved major drug compendia do not contain any comparative efficacy data showing Evenity 
would be more effective than zoledronic acid or Prolia for treatment of this enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
29, 2022, to February 27, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled care. 
 
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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from January 29, 2022, to February 27, 2022.