Persius/hicric huggingface dataset:
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 occupational therapy is required because the member 
is a fall risk and is unable to walk. The Plan denied your request. The Plan says the IRF services requested 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 does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pantoprazole. 
 
You asked the Plan to pre-approve pantoprazole. You say that you were told that you needed prior 
authorization. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 pantoprazole.  
 Benefits for pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for office visits (99233) provided on June 13, 2022 to June 14, 2022. 
 
You asked the Plan to pay for the office visits. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that this service was included in another service. 
 
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 articulate the reason for this denial. The Explanation of 
Benefits state that the services billed are included in another service billed, however no information is provided 
about other services billed. Therefore, we decided that the Plan has to pay for office visits (99233) provided on 
June 13, 2022 to June 14, 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met, he enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care, a Skilled Nursing Facility, on an intermittent basis at 
home with home health care, or in a long-term care setting 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory virus panel (87486, 87798, 87496, 87498, 
87502, 87532, 87541, 87581, 87634, and 87640) provided on January 5, 2022. 
 
You asked the Plan to pay for the respiratory virus panel. You say that these services were performed by a 
certified laboratory at the request of the enrollee's treating physician. The Plan denied your request. The Plan 
says these services are considered non-covered and not medically necessary as this was a multiplex PCR 
respiratory viral panel of more than 6 pathogens. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory virus panel have not been met. Specifically, this was a multiplex PCR respiratory 
viral panel of more than 6 pathogens. Therefore, we decided that the Plan does not have to pay for the 
respiratory virus panel (87486, 87798, 87496, 87498, 87502, 87532, 87541, 87581, 87634, and 87640) 
provided on January 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lamotrigine tablets. 
 
You asked the Plan to pre-approve Lamotrigine tablets. You say that the member's medical condition requires 
this medication. The Plan denied your request. The Plan says self-administered drugs are not covered under 
Medicare Part B. 
 
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 Lamotrigine tablets.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
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 Gammagard. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Gammagard is not FDA-approved for the enrollees diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Gammagard (J1569).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no evaluation of bone mass density, or been started on osteoporosis 
treatment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding a neurological exam having been documented as 
performed to rule out neurological deficit. The magnetic resonance imaging (MRI) demonstrated potential 
stenosis. Moreover, there is noted 2mm retropulsion noted at the L1 compression fracture. Therefore, the 
enrollee does not meet the criteria for this requested procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone sodium phosphate, Famotidine, 
Diphenhydramine Hcl, Carboplatin, and Paclitaxel. 
 
You asked the Plan to pre-approve Dexamethasone sodium phosphate, Famotidine, Diphenhydramine Hcl, 
Carboplatin, and Paclitaxel. 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 may pay for unlabeled uses for anti-cancer 
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 Dexamethasone sodium phosphate, 
Famotidine, Diphenhydramine Hcl, Carboplatin, and Paclitaxel. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the use of the requested drugs are not FDA-approved for 
the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dexamethasone sodium phosphate, Famotidine, Diphenhydramine Hcl, 
Carboplatin, and Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-
approve Dexamethasone sodium phosphate, Famotidine, Diphenhydramine Hcl, Carboplatin, and Paclitaxel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 7, 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 the enrollee requires close medical supervision with 
specialized nursing care throughout the day. The Plan denied your request. The Plan says the enrollee does not 
require an intensive level of therapy requiring physician oversight. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is to be assessed both medically and 
functionally in regard to premorbid functional capacity to determine whether to benefit from a rehabilitation 
level of care offered by mentioned facility. The Plan denied your request. The Plan says the enrollee's records 
do not show that you need at least two therapies, or the need of intensity of services provided in the IRF setting, 
medically necessary care may be provided safely in a different 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 enrollee's nursing, medical and rehabilitation needs does not 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651). 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support this 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the pneumatic compression device 
have been met. No clinical records were provided to show that coverage criteria for this equipment is met. No 
physician order was provided for the requested equipment. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0651).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Denosumab injection, 1 mg (Prolia) (J0897). 
 
You asked the Plan to pre-approve Prolia injection. You say that the Prolia is supplied by the pharmacy ad 
given in the office. Please reconsider the authorization request and approve. The Plan denied your request. The 
Plan says this medication falls under Part D coverage. Drugs covered under Part D are not eligible for coverage 
under Part B benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve the Denosumab injection, 1 mg (Prolia) (J0897).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (code 99225) provided on 
April 26, 2022. 
 
You asked the Plan to pay for the subsequent observation care. You say that the care was medically necessary. 
The Plan denied your request. The Plan says services from non-par providers are not covered under an HMO 
plan unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent observation care (code 99225) provided on 
April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy, surgical, repair of paraesophageal hernia, 
includes fundoplasty, when performed (43282) provided September 19, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that please review the attached documents and 
reconsider payment to the second assistant surgeon The Plan denied your request. The Plan says Medicare pays 
for an assistant at surgery only when the procedure is authorized for an assistant. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy, surgical, repair of 
paraesophageal hernia, includes fundoplasty, when performed (43282) provided September 19, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. 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. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.