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

 
We decided that the Plan does not have to pre-approve Kerendia 20MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Kerendia is a self-administered drug and does not fall under Part B coverage. 
 
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 Kerendia 20MG tablet.  
 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment every 4 weeks with Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the dosing frequency prescribed is off-label and not 
medically accepted. 
 
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 Entyvio. Our reviewer says that the 
requested drug regimen is medically reasonable and necessary in this case. Our physician reviewer found that 
studies suggest that increased dosing frequency of Entyvio might improve outcomes in patients who lose 
response to conventional 8-weekly dosing. Optimization of Entyvio dosed every 4 weeks is considered 
medically necessary as a Plan-policy exception for the enrollee for one year with re-evaluation thereafter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have been met. Therefore, we decided that the Plan has to pre-approve 
treatment every 4 weeks with Entyvio.  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 was admitted with acute hypoxic respiratory failure and sepsis in the 
setting of aspiration pneumonia. The record indicates the enrollee continues to have acute encephalopathy and 
still requires acute care services. The enrollee is receiving appropriate care at the present setting. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 you have been at the medical center for the past 
twenty-six days and need acute rehabilitation as soon as possible. The Plan denied your request. The Plan says 
based on the review of additional information received, it was determined that you do not meet criteria for 
acute inpatient rehabilitation 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 there is no documentation that in the last 30 days you had surgery, was on a 
ventilator, had a malignancy, multiple traumas, myopathy, a progressive degenerative neuromuscular disorder, 
systemic vasculitis with joint inflammation or uncontrolled pain and failed outpatient or short-term 
rehabilitation. Although you have multiple comorbid conditions, there is no indication you require more 
frequent medical professional follow-ups that is available at a short-term rehabilitation. There are no complex 
nursing or rehabilitation needs. While you have a need for physical 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. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (dental code D9944). 
 
You asked the Plan to pre-approve the dental services. You say that you accidental threw out your occlusal 
guard and really need it. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 13, 2022. Therefore, 
we decided that the Plan does not have to pre-approve an occlusal guard (dental code D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490 and 64491 billed for date of service 
January 27, 2022. 
 
You asked the Plan to pay for procedure codes 64490 and 64491. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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. Medicare rules say that providers must report 
services correctly. 
 
In this case, the MUE for CPT codes 64490 and 64491 is 1. The MAI value for these codes is 2. You billed 2 
units of each of these codes, exceeding the MUE. Additionally, these codes have a bilateral surgery indicator of 
1. This means the codes should be reported with 1 unit of service and modifier 50 (bilateral modifier) to be 
considered for payment. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 64490 and 64491 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 64490 and 64491 billed for date of service January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that the Plan network does not provide the 
recommended treatment of CAR-T cell therapy. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee 
can be treated by an in-network provider, including the recommended CAR-T cell therapy. 
 
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 
outpatient treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that the Plan network cannot provide the 
recommended treatment of CAR-T cell therapy. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee 
can be treated by an in-network provider, including the recommended CAR-T cell therapy. 
 
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 
outpatient treatment 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 4 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the home PT visits. You say that you fell on your last visit with physical 
therapy, and you feel that you need more help. The Plan denied your request. The Plan says it is felt that the 
enrollee is stable to continue rehabilitation with the home exercise program and follow up with their physician. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home PT visits. Our reviewer says 
that the enrollee does not meet the Medicare criteria for home health services. Our physician reviewer found as 
of 07/25/2022 the enrollee was walking 100 feet with a rolling walker with stand-by assistance and was 
modified independent for transfers. Based on the available records the enrollee appears to have improved with 
therapy to the point of being able to manage walking household distances with a rolling walker with stand-by assistance and is modified independent for transfers. After 23 physical therapy treatments, records do not 
support that the complexity of the enrollees conditions are such that the skills of a professional therapist are 
required to achieve further improvement in the enrollee's symptoms or functional status. Further utilization of 
the home exercise program appears appropriate at this point. No medical notes from the enrollees treating 
physician are provided documenting an order or need for additional skilled physical therapy services beyond 
what have already been provided. 
 
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 home PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 4 additional home health physical therapy (PT) visits.
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 you ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at a Skilled Nursing Facility, on an intermittent basis at home with home health care, or in a long-term 
care setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. You can 
receive further services 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 9, 2021, billed with 
codes 81240, 81291, 81241, 81230, 81225, 81406, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 9, 2021, billed with codes 81240, 81291, 81241, 81230, 81225, 81406, and 81408.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you need physical therapy while 
traveling. You say that you have been advised that you need the therapy to be continuous to strengthen your 
ankle and a gap in therapy will set you back. The Plan denied your request. The Plan says the services you 
requested are not considered urgent or unforeseen (unexpected) medical care. 
 
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 
physical therapy visits to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis, single upright, thigh and calf, with 
adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or 
without varus/valgus adjustment, prefabricated, off-the-shelf (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that services are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee's records show 
that she does not have objective findings of knee instability. 
 
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 a knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records show that the enrollee has severe medial tricompartmental arthritis of her left knee. The 
enrollee reported issues with instability during ambulation. Examination was notable for normal visual 
overview, with pain on palpation of the medial joint line of the left knee. The case file does not contain 
objective documentation of instability, deformity, or ligament tears. The documentation does not support that 
the knee orthosis at issue is medically reasonable and necessary for the enrollee 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 a knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint 
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 
prefabricated, off-the-shelf (L1851).