Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that the enrollee is not a candidate for oral biologics, 
and is not able to provide injections due to needle fear. The Plan denied your request. The Plan says the denial 
of authorization for this drug is correct, because the Plan requires a trial of Humira, Enbrel, Xeljanz, or Rinvoq 
before it will approve Simponi Aria.  
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 Simponi Aria. Our reviewer says that 
the enrollee does not meet the Medicare criteria for a step therapy exception for Simponi Aria. Our physician 
reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Humira, Enbrel, Xeljanz, or 
Rinvoq. The record does not show that these drugs would likely be less effective and/or 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 Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Simponi Aria.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment simulation using three-dimensional (3D) image 
volume (D0393) provided on November 16, 2021. 
 
You asked the Plan to pay for the treatment simulation using 3D image volume. You say that this same 
procedure was approved in June 2021, and the dentist accepts your insurance. The Plan denied your request. 
The Plan says this procedure is not included in the benefits section of your Evidence of Coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment simulation using three-dimensional (3D) image volume (D0393) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult for bone marrow transplant evaluation to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network specialists as well as tertiary providers available 
that can provide the services at issue in this request. 
 
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 
a consult for bone marrow transplant evaluation to be provided by an out-of-network provider.
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 unable to return home due to multiple 
medical issues. You also say that the enrollee does not want to return to a skilled nursing facility. The Plan 
denied your request. The Plan says the IRF admission is not medically necessary. 
 
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 provided documentation indicates that the enrollee's medical problems are 
stable and does not have complex nursing or rehabilitation needs. The reviewer found that while the enrollee 
has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. The reviewer also found that 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. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740), and a core build-up (D2950) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown (D2740) and a core build-up. You say that dental records and x-
ray(s) support the decay on tooth #9 is close to or into the pulp. The Plan denied your request. The Plan says 
that the medical criteria for D2740 and D2950 have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown 
(D2740) and a core build-up when the services are medically necessary and reasonable. 
 
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 a crown (D2740) and a core build-up. 
Our physician reviewer found the documentation provided meets the criteria for coverage for D2950 and 
D2740 for tooth #9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown (D2740) and a core build-up have been met. Therefore, we decided that 
the Plan has to pre-approve a crown (D2740), and a core build-up (D2950) to be provided by a participating 
provider. 
 
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. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 member's medical conditions are stable and there are no complex nursing or 
rehabilitation needs. While the member may have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. 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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 your medical conditions are stable and there are no complex nursing or rehabilitation 
needs. While you may have a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. 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 the enrollee cannot be optimally restored 
at any other level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and does not require transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute hospital from skilled nursing facility with acute 
hypoxic respiratory failure secondary to pneumonia. Recent notes showed continued improvement of 
pulmonary opacities. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care.  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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve forty-two (42) additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are requesting 
additional routine transportation. The Plan denied your request. The Plan says this request exhausts your 
benefit allowance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The requested amount exceeds 
the limit listed by the plan. Your 2022 EOC states, up to 48 one-way trips are covered each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve forty-two (42) 
additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Faslodex (CPT code J9395). 
 You asked the Plan to pre-approve the medication. You say that the medication is necessary for the enrollee's 
cancer treatment. The Plan denied your request. The Plan says they cannot require pre-approval for services 
related to clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medication as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Faslodex (CPT code J9395).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the required services cannot safely be met with home 
health services or a SNF at this time. You say that the enrollee requires rehabilitation in an effort to facilitate 
independence and return home with an improved quality of life. The Plan denied your request. The Plan says 
the enrollee can safely receive the services 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 enrollee is medically stable and does not need physician supervision 3 times 
per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no rehab nursing needs identified or documented in the record. IRF admission is not medically 
necessary based on medical stability, lack of medical complexity, and lack of rehab nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J2922). 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary for the 
enrollee's diagnosis. You also say that they need to start treatment as soon as possible. The Plan denied your 
request. The Plan says the use of this drug in your case requires that it is being used as a single agent for the 
enrollee's condition. 
 
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 Opdivo. Our reviewer says that the 
requested drug, Opdivo, is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the appeal information is inconsistent with the medical records and no clarifying records have 
been submitted. The reviewer found that the Food and Drug Administration (FDA) has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo (J2922).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional skilled nursing visits (G0151). 
 You asked the Plan to pre-approve home health services. You say that the enrollee requires wound care for 
chronic wounds. You also say that the enrollee is unable to do this on their own. The Plan denied your request. 
The Plan says the requested services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the wound care being provided is complex. The reviewer found 
that the enrollee lives in a facility with 24/7 assistance. As such, the requested home health services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional skilled nursing visits (G0151).
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. The Plan denied your request. The Plan says you do 
not need care that can only be provided in a hospital. 
 
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 physician 
reviewer found that you were admitted to the acute care hospital with an infected sacral wound. The record 
indicates that you are improving but still require ongoing acute care services. You continue to receive acute 
care services, and these have not been denied. The medical record does not indicate that you require services 
that you are not currently receiving but that would be available at the LTACH facility. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections (64494) provided on September 30, 
2021.  You asked the Plan to pay for the facet joint injections (64494). You say that  The Plan denied your request. 
The Plan says CPT code 64494-LT and 64494-RT were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the facet 
joint injections (64494) have not been met. Therefore, we decided that the Plan does not have to pay for the 
facet joint injections (64494) provided on September 30, 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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility, home with home health and home physical therapy, or home with outpatient therapy. 
 
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 the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met at a lower 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.