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

 
We decided that the Plan does not have to pre-approve Rybelsus (CPT code J8499). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug is intended for patient self-administration and is not covered 
by the enrollee's Part B benefits. 
 
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 Rybelsus (CPT code 
J8499).  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ossur Total Knee 2000. 
 
You asked the Plan to pre-approve the Ossur Total Knee 2000. You say that you would like reconsideration 
because the requested prosthetic is medically necessary. The Plan denied your request. The Plan says the 
requested part is unbundled from the approved knee and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that the DME MACs and the Pricing, Data Analysis, 
and Coding (PDAC) contractor are responsible for assigning individual DMEPOS products to HCPCS code 
categories for billing Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Ossur Total Knee 2000 have not been met. Specifically, review of DME PDAC shows that the requested knee is not listed for use with CPT code L5845. L5845 cannot be used for this device. Therefore, we 
decided that the Plan does not have to pre-approve the Ossur Total Knee 2000.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy services provided 
from July 20, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayments for physical therapy. You say that these services were pre-
approved, and you did not have to pay for your previous physical therapy sessions at home. The Plan denied 
your request. The Plan says these claims were processed correctly, and your copayments were assessed in 
accordance with your contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered physical therapy services.  
 
You have been asked to pay a $40 copayment for each physical therapy visit. The record shows that you had 
previously been approved for home health agency services from April 23, 2021, through June 23, 2021. These 
services included physical therapy and required a $0 copayment. After the approval for home health agency 
services expired, you wanted to continue receiving physical therapy at home. Some outpatient services can be 
provided in the home, but this does not make them the same as home health agency services. On the dates in question, you were approved for physical therapy, but you did not meet the criteria for continuation of home 
health care. Therefore, the outpatient physical therapy copayment applies for the services in this case. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the physical therapy services provided from July 20, 2021, 
to September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Nurtec.  
 
Benefits for Nurtec 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea for the enrollee. 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred products. 
 
 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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary. The patient has not tried and failed the required drug, bevacizumab 
(Avastin). There is no indication that the Plan's required drug would likely be less effective and/or likely have 
adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step 
therapy criteria for Eylea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injection. 
 
You asked the Plan to pre-approve Dupixent. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Dupixent injection.  
 Benefits for Dupixent 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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he/she 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 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.
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 are weak, dizzy, and have been in the hospital 
for 2 weeks. You say that you have fallen several times and require rehabilitation as soon as possible in a 
hospital setting. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee could receive care in another 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. The 
enrollee was admitted for anemia and gastrointestinal bleeding. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. 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: 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's health is already being jeopardized, as 
she has not been getting therapy. The Plan denied your request. The Plan says the guidelines for coverage have 
not been met. The Plan says that the enrollee could receive care in another 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. The 
enrollee was admitted for respiratory failure and pneumonia. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. 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: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 29, 2021. 
 You asked the Plan to pay for the eye refraction. You say that these services were necessary, and they were 
ordered by your physician. The Plan denied your request. The Plan says the eye refraction in this case was 
provided as part of a medical eye exam. Eye refractions may only be covered by the Plan once per year when 
they are performed as part of a routine (non-medical) eye exam. 
 
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 eye refractions only when they are performed as part of a routine (non-medical) eye 
exam to evaluate the need to eyeglasses/contacts. 
 
We looked at the file and the Plan's rules. The eye exam in this case was provided for medical purposes. Based 
on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 
29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic (CPT code J3490). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug is intended for patient self-administration and is not covered 
by the enrollee's Part B benefits. 
 
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 Ozempic (CPT code 
J3490).  
 
Benefits for the medication 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
for respiratory failure and congestive heart failure and were transferred to a skilled nursing facility on March 25, 2022. Your medical problems are now stable and you have 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist. 
 
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 the services are available from network providers. 
 
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 referral to an out-of-network dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99212) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this doctor is well trained in the link between 
wheat sensitivity and osteoporosis. You do not feel comfortable with a doctor that does not have that type of 
specific training. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99212) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide services (T1021). 
 
You asked the Plan to pre-approve the home health aide services. You say that these services are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence that the 
enrollee is homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve the home health aide services (T1021).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health physical therapy services. You say that this care is medically 
necessary. The Plan denied your request. The Plan says there is no network deficiency for these services. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted documentation does not 
contain any records to support that the definitive drug testing meets the Medicare criteria for coverage. The 
services were not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on October 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on September 8, 
2021. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that this was a screening you do every 
year, and the Plan has paid 100% previously. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105 
copayment for in-network basic radiological services. The Plan contract also says that enrollees have $0 cost 
share for low dose computed tomography (LDCT) for lung cancer screening. 
 
The EOC states the Plan covers a LDCT for lung cancer screening. A LDCT scan is a different test than the 
chest x-ray you had on September 8, 2021. You have been asked to pay the allowed amount of $72.18, which is 
less than the $105 copayment for a chest x-ray. A chest x-ray falls within the Outpatient Hospital Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a chest x-ray provided on 
September 8, 2021.