Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have 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 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found at the time of 
discharge from the hospital the member had stabilized medically. The member did not require any skilled 
nursing or rehab services on a daily basis at an inpatient level of care. He was not expected to make measurable 
gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or self-care tasks. The member did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, the member did not require any skilled services on an inpatient 
basis, at a SNF level of care at the time of discharge from the hospital. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is not 
prescribed for a medically accepted indication. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that you 
have a diagnosis of osteopenia at risk for osteoporosis. The FDA has not stated that the requested drug is 
indicated for your condition. The Medicare-approved drug compendia do not contain a supportive citation for 
the use of the requested drug in your clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine surgery (Superion Interspinous Spacer). 
 
You asked the Plan to pre-approve superion interspinous spacer. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has spinal stenosis. The Superion spacer is experimental. More 
research is needed. Therefore, the enrollee does not meet criteria for the requested 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 superion interspinous spacer have not been met. 
 
  
 Therefore, we decided that the Plan does not have to pre-approve lumbar spine surgery (Superion Interspinous 
Spacer).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the eye exam (92012) provided on 
February 1, 2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that you would like the copay amount 
to be reduced to the specialist copay amount of $45. You also say that you do not feel you should have to pay 
the extra $5 for the difference between an eye visit and a specialist. The Plan denied your request. The Plan 
says you pay a $50.00 copayment for an eye exam from an in-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers Outpatient physician services for the diagnosis and treatment of diseases and injuries 
of the eye, including treatment for age-related macular degeneration, and you must pay a $50 copayment. 
 
We looked at the file and the Plan's rules. You are responsible for a $50 copayment. Based on this information, 
we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the 
Plan does not have to reduce the copayment for the eye exam (92012) provided on February 1, 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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated 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 while the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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 pre-approve the trigger point injection and the lumbar medial branch 
block procedure to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the trigger point injection and the lumbar medial branch block procedure. 
You say that it is medically necessary to treat the enrollee. The Plan denied your request. The Plan says the 
requesting provider of services is an OON provider and there are in-network providers that can treat the 
enrollee. 
 
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 
the trigger point injection and the lumbar medial branch block procedure to be provided by an out-of-network 
(OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you have poor quality of life due to pain. You say 
that you are in constant excruciating pain and need the injection to improve symptoms. The Plan denied your 
request. The Plan says you have not tried one of the preferred drugs or show that you have medical reasons that 
prevent you from using one of them. 
  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 Euflexxa. Our reviewer says that 
Euflexxa is not indicated at this time. Our physician reviewer found there is no documentation of first line 
treatment with Orthovisc or Monovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 11, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) provided 
on October 14, 2021. 
 
You asked the Plan to pay for the TAVR. You did not provide a specific argument for coverage with your 
appeal request. The Plan denied your request. The Plan says you did not bill this service correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that services related to TAVR are only covered when 
performed as part of a CED study.  The rules say that for any services performed as part of a CED study, you 
must report the clinical trial number on the claim.  You did not include a clinical trial number on the claim you 
submitted. Based on this information, we decided that Medicare rules for coverage of the TAVR have not been 
met. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement 
(TAVR) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator and electrodes provided by a 
chiropractor on September 22, 2020. 
 
You asked the Plan to pay for the electrical nerve stimulator and electrodes. You say that the patient was 
referred for care with you by a network provider. The Plan denied your request. The Plan says these services 
are not covered when furnished by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the items at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical nerve stimulator and electrodes provided by a chiropractor on 
September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you have a difficult time using the 
lancets and are using them four times per day. The Plan denied your request. The Plan says you do not meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a FreeStyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor 
(CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 8, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service and the reports support the level of service. You say that the claim should be considered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of extensive eczematous or infected skin 
(11000) billed for date of service October 14, 2021. 
 
You asked the Plan to pay for a debridement of extensive eczematous or infected skin. You say that you have 
provided medical records to support the service at issue. The Plan denied your request. The Plan says rules for 
payment have not been met because the available records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11000 is "Debridement of extensive eczematous or 
infected skin; up to 10% of body surface." 
 
We asked our coder 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 a debridement of extensive eczematous or infected skin. Our 
reviewer says that the billed service does not meet criteria for payment. Our reviewer found that the available procedure report does not include a description of debridement of extensive eczematous or infected skin. The 
operative report describes irrigation debridement; however, extensive eczematous or infected skin cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a debridement of extensive eczematous or infected skin have not been met. 
Therefore, we decided that the Plan does not have to pay for a debridement of extensive eczematous or infected 
skin (11000) billed for date of service October 14, 2021.
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 patient was admitted for surgical repair of a femur fracture after a fall. 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. In conclusion, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transport (A0429) and ground 
mileage (A0425) provided on March 20, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency ambulance transport (A0429) and ground 
mileage (A0425) provided on March 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prochlorperazine tablet. 
 
You asked the Plan to pre-approve Prochlorperazine. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered anti-emetic 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare extends coverage to self-administered anti-
emetic drugs when the conditions listed in the Medicare rules section have been met. 
 
In this case, the case record indicates that the requested oral anti-emetic drug will not be used as a full 
therapeutic replacement for intravenous anti-emetic drugs that would have been administered at the time of the 
chemotherapy treatment. Based on this information, we decided that Medicare rules for coverage of Prochlorperazine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
treatment with Prochlorperazine tablet.  
 
Benefits for Prochlorperazine 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: 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 LTACH is medically necessary for 
the enrollee's care. The Plan denied your request. The Plan says the enrollee's conditions are not sufficiently 
complex or severe to require LTACH level of 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 the enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to an LTACH is not medically necessary, as it would not be clinically 
advantageous. 
 
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.