Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure because of the wide variation in efficacy in 
the published 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. 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 the enrollee was admitted with acute hypercapnic respiratory failure due to COVID-
19 pneumonia and sepsis. The record indicates that the enrollee is improving but still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy/discectomy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says further studies within a higher level of evidence, particularly those of a prospective 
nature, are needed. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found percutaneous lumbar discectomy remains experimental. More research is needed to show safety and 
efficacy of this procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar laminectomy/discectomy for the enrollee.
Appeal type: Step-Therapy
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 this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 the 
requested drug is not medically necessary for the enrollee's condition. Our physician reviewer found the Plan 
requires a trial of Forte before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
would likely be less effective and/or likely 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9374) provided from August 31, 
2021, through September 5, 2021. 
 
You asked the Plan to pay for the home infusion therapy (S9374). You say that the attached records support 
this claim, and the claim should be processed for payment. The Plan denied your request. The Plan says the 
billed code is not valid for Medicare purposes. 
 
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 S9374 is home infusion therapy, hydration therapy; one 
liter per day, administrative services, professional pharmacy services, care coordination, and all necessary 
supplies and equipment (drugs and nursing visits coded separately), per diem.  
We find that CPT code S9374 is not supported in the medical record. Specifically, CPT code S9374 has a status 
indicator of I. This means that CPT code S9374 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the home infusion therapy (S9374) have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9374) provided from 
August 31, 2021, through September 5, 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 the IRF care. The Plan denied your request. The Plan says this request does 
not meet criteria, is not medically necessary, and a lower level of care might be appropriate. 
 
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 the 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 is medically stable and does not need physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. Our reviewer found that 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. Our physician 
reviewer also found that the enrollee's needs can be met in a less intense setting such as a skilled nursing 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for A9552- Fluorodeoxyglucose provided on 
July 21, 2021. 
 
You asked the Plan to waive the coinsurance for A9552- Fluorodeoxyglucose. You say that you wanted to 
know why the approved amount is $250 and is not covered in full by the Plan. You also that you wanted to 
know why you have to pay your 20% share. 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 20% 
coinsurance for medical supplies.  
 
 The records show that A9552- Fluorodeoxyglucose is a separately paid code by the Plan as a medical supply. 
You have been asked to pay $50, which is 20% of the allowed amount for A9552- Fluorodeoxyglucose ($250 
allowed amount x 20% coinsurance = $50). A9552- Fluorodeoxyglucose falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 coinsurance 
for A9552- Fluorodeoxyglucose provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services (97110 and 97530) 
provided on December 13, 2019 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the occupational therapy services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the treating provider is not a network 
provider with the Plan, and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that these services are not urgent or emergent, nor were they approved in advance. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the occupational therapy services (97110 and 
97530) provided on December 13, 2019 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Daliresp 500 mcg tablet. 
 
You asked the Plan to pre-approve Daliresp. You say that this drug is medically reasonable and 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 Daliresp 500 mcg tablet.  
 
Benefits for Daliresp 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 continued inpatient psychiatric care as of March 7, 
2022. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for continued inpatient care is 
correct, because the enrollee does not require 24-hour inpatient care and can step down to a less intensive 
setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of March 7, 
2022. Our physician reviewer found it is not expected that the enrollee will improve in a reasonable period of 
time beyond the date in question as the enrollee was not showing any dangerousness to self or others, auditory 
or visual hallucinations, or aggressive behaviors. The enrollee was cooperative and compliant with medication. 
It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital stay provided from February 22, 2021, to 
February 27, 2021. 
 
You asked the Plan to pay for the inpatient hospital stays. The Plan denied your request. The Plan says that the 
enrollee did not meet medical necessity for an inpatient level of care. The Plan also says that the provider could 
have provided care safely and effectively at an alternate level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 the inpatient hospital stay. Our reviewer says 
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 inpatient hospital stay have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital stay provided from February 22, 2021, to February 27, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection (S0020) provided on 
September 1, 2021. 
 
You asked the Plan to pay for the bupivicaine hydrochloride injection (S0020). You say that medical records 
show the procedure meets L34588 guidelines. The Plan denied your request. The Plan says the billed code is 
not valid for Medicare purposes. 
 
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 S0020 is injection, bupivicaine hydrochloride, 30 ml. 
 
 
  We find that CPT code S0020 is not supported in the medical record. Specifically, CPT code S0020 has a status 
indicator of I. This means that CPT code S0020 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the bupivicaine hydrochloride injection (S0020) have not been 
met. Therefore, we decided that the Plan does not have to pay for the bupivicaine hydrochloride injection 
(S0020) provided on September 1, 2021.
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 
the enrollee's 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 the beneficiary is an 88-year-old female with 
pelvic fractures after a fall. In this case, there are no identifiable skilled nursing service needs and no 
identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services 
on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria 
for 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 admission to a skilled nursing facility (SNF).
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that you are trying to save the enrollee's vision. The Plan 
denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan 
requires a trial of Avastin before it will approve Eylea. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare covers Part B medications when they are reasonable and necessary but allows health plans 
to implement step therapy criteria. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan contract does not clearly state that Medicare Part B drug step therapy 
criteria have been implemented that would be applicable to Eylea. The Plan submitted a Medicare Part B 
preferred drug list, but the enrollees contract with the Plan does not show that the enrollee is contractually 
obligated to try a preferred drug such as Avastin before using Eylea. The Plan submitted additional information 
stating that the Plan would submit additional contractual documents, but these documents were not actually 
submitted. Therefore, the Plan has not shown that its decision to deny authorization for Eylea is correct or 
justified according to Medicare rules and the enrollees contract with the Plan. Therefore, we decided that the 
Plan has to pre-approve use of Eylea.  
 
 
 
 
  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary for chronic back pain. 
The Plan denied your request. The Plan says the records do not show the required documentation of degree of 
pain relief from the diagnostic injections. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the records do not show the required documentation of pain relief from 
the medial branch blocks. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve paravertebral facet joint radiofrequency ablation.