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 for
your condition. 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 daily
skilled services are not necessary. Our physician reviewer found that you are a 58-year-old female with a past
medical history of diabetes, hypertension, sarcoidosis and rheumatoid arthritis who presented to the acute
hospital on February 4 for an elective C6-C7 disc replacement due to cervical radiculopathy symptoms. You
underwent an uncomplicated surgery, and your post-operative course has been stable. While you do require
skilled therapy services, these services are not required on a daily basis. You are walking more than household
distances with stand-by assistance. Based on the medical records provided you do not require the services on an
inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a
long-term care facility on a part time basis appear 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 admission to a skilled nursing facility (SNF).
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 Evenity is medically necessary. The Plan denied your
request. The Plan says a trial of Prolia and Oral Bisphosphonates is required before Evenity can be considered.
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 Evenity
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred
drugs or any reason they would be unsafe or ineffective 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your
request. The Plan says this request is covered under Medicare Part D.
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 Retacrit.
Benefits for Retacrit 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: 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 SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled nursing or skilled therapy services on a daily basis in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria have not been satisfied.
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 Procrit. Our reviewer says that the
requested drug is not medically reasonable and necessary based on step therapy criteria. Our physician
reviewer found the Plan requires a trial of Aranesp or Retacrit before they will approve the requested drug,
Procrit. Based on the medical records provided the patient has not tried and failed the required drug(s). Based
on the medical records provided there is no indication that the plan's required drug(s) would likely be less
effective and/or likely have adverse effects 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 Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit.
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 for the enrollee.
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 the member's care needs could be met with either admission to a skilled
nursing facility or with home health.
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
enrollee has debility with previous stroke and is medically stable. With her comorbid conditions being stable,
she does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum)
for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no
acute or complex rehab nursing needs noted in the record. The enrollee does not need intensive therapies,
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to
daily therapy. For his debility, she does not require skilled therapists' interventions except routine care.
Additionally, at the current level of dependency, she is not expected to make a significant progress in a
reasonable period of time in an IRF and benefit from it. While the enrollee may benefit from physical and
occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting
such as in an SNF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) provided
August 31, 2021, and September 14, 2021.
You asked the Plan to pay for the gingival irrigation. You say that this service should be covered. The Plan
denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
gingival irrigation - per quadrant (D4921) provided August 31, 2021, and September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on October 8,
2021.
You asked the Plan to pay for an annual wellness visit. You say that you were told you needed to have your
annual wellness visit. The Plan denied your request. The Plan says this exceeds the frequency limitation.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on
October 8, 2021.
Your complaint about the correspondence you received from the Plan regarding your visits is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 9,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.
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 70544
is a column II code to column I code 70551. 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 imaging services provided to the enrollee on September 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided from June 15, 2021
to June 22, 2021.
You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan
denied your request. The Plan says this was not billed with a valid code.
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 S9502 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided from
June 15, 2021 to June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan from the
skull base to mid-thigh (78815).
You asked the Plan to pre-approve PET scan services. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says PET scan services are not supported for the
first staging of prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that a FDG PET scan for the initial treatment strategy
of prostate cancer is not covered.
We looked at the file and Medicare rules. The file shows that this PET scan is requested for the initial treatment
of the enrollee's prostate cancer which is not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of PET scan services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a positron emission tomography (PET) scan from the skull base to mid-thigh (78815).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec.
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 self-administered drugs are not covered.
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 Nurtec.
Benefits for these services 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: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on March 10, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services
are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is
inappropriate for a patient to visit his/her physician, physical therapist, or an outpatient clinic on a continuing
basis for treatment of pain with electrical nerve stimulation. The file shows that the enrollee received
vasopneumatic device treatment services. Treatment of lymphedema by a provider after the educational visits is
generally not medically necessary. The file shows that a nutria-pharmaceutical injection was billed using
multiple codes. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999.
As this compounded drug was not billed properly, payment cannot be made. Based on this information, we
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the pain management services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the
enrollee on January 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this code cannot be paid separately.
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 99100 is "Anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)."
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment
for other services not specified. 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 pay for anesthesia services
(procedure code 99100) provided to the enrollee on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and the fundus photography with
interpretation and report (92250) rendered by the out-of-network (OON) provider on March 31, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 Plan had network providers available
who could have provided the services at issue in this appeal. 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 the office visit (99213) and the fundus photography with interpretation and report
(92250) rendered by the out-of-network (OON) provider on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI)
joint.
You asked the Plan to pre-approve RFA to the SI joint. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says this is an experimental/investigational
procedure.
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 RFA to the SI joint. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is a 61-year-old morbidly obese woman who has chronic low back and
knee pain. She also has sacroiliitis. The requested RFA to SI joint is considered an experimental/
investigational procedure because of the wide variation in efficacy reported in the literature. Therefore, the
request is considered not medically reasonable or 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
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 inpatient rehabilitation services. The Plan
denied your request. The Plan says the criteria for admission to an IRF are not met. You do not need three
hours a day of therapy and your medical conditions are stable. Your needs can be met in a less intensive
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 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. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary 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 inpatient rehabilitation facility (IRF) admission and services.
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 LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of LTACH services.
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 are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
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.