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

We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Repatha SureClick is not covered under the enrollee's 
Medicare Part B 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 Repatha SureClick.  
 
Benefits for Repatha SureClick 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 admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

You have a past medical history of multiple myeloma, spinal surgery, chronic back pain, who is living at home 
with progressive weakness. Medical problems are stable. There are 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 the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80050, 84153, and 84480 
provided on November 27, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 rendered 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 84480 
for the laboratory services has a bundled relationship with code 84481 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80050, 84153, and 
84480 provided on November 27, 2020.
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. 
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 based on the medical records provided this 
patient does require skilled therapy services. However, there is no documentation that the patient requires 
skilled nursing services. In addition, daily skilled services are not required. Based on the medical records 
provided this patient does not require the services on an inpatient basis, only in a skilled nursing facility setting.  
Services in the assisted living facility with home health care or in a long-term care facility on a part time basis 
appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Entyvio. 
 
You asked the Plan to pay for Entyvio. You say that this is medically necessary. The Plan denied your request. 
The Plan says this is not indicated for the enrollee's condition. 
 
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 pay for Entyvio. Our reviewer says that the 
requested use of Entyvio is not supported. Our physician reviewer found the record indicates that the enrollee 
has lymphocytic colitis. The Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. 

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 not been met. Therefore, we decided that the Plan does not have 
to pay for Entyvio.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76856 provided on June 11, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the services billed are not separately payable. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76856 
for the ultrasound has a bundled relationship with code 93975 and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76856 provided on June 11, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulation device. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says stroke is 
not a covered indication for use of the requested device. 

The Plan must follow Medicare rules. Medicare rules say that neuromuscular electrical stimulation is only 
covered under certain medical indications.   
 
The file shows that a Bioness electrical stimulation device was requested. We looked at the file and Medicare 
rules. In this case, there were no medical records from your treating physician to show the coverage criteria for 
an electrical stimulation device have been met. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a neuromuscular 
electrical stimulation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says none of the requirement for this stay have been met. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.

Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The planned procedure listed under CPT code 27999 is not listed on the CMS 
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The 
review has determined that the enrollee does not require an inpatient stay for the approved excision of right hip 
heterotopic ossification. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for SNF care is correct. 
 
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 enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Botox injection.  
You asked the Plan to pre-approve the requested services. You say that the enrollee has been improving with 
the injections. The Plan denied your request. The Plan says you have not had any improvement in your 
migraines.  
The Plan must follow Medicare rules. Medicare rules say that Botulinum toxins are only covered under certain 
medical indications.  

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 requested services. Our physician 
reviewer found that the enrollee has a history of migraines. In this case, the enrollee has had a migraine every 
day since the Botox injection July 22, 2021.   
 
According to the coverage criteria for continuing Botulism toxin therapy, the enrollee must demonstrate a 
significant decrease in the number and frequency of headaches and an improvement in function upon receiving 
Botulinum toxin. The review has determined that the enrollee does not meet the coverage criteria for a repeat 
injection. Therefore, the requested treatment is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat Botox injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. 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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of zoledronic acid or a history of osteoporosis-related fracture before they will approve the requested drug. In 
this case, the patient has not tried and failed zoledronic acid and does not have a history of osteoporosis-related 
fracture. There is no documentation provided indicating that zoledronic acid would likely be less effective or 
have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 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 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on October 17, 2021 for management of hypoxia and respiratory distress. He continues 
to have coughing and congestion with need for scheduled albuterol and oral prednisone. There is no 
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the 
present acute care hospital. 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hepatobiliary system imaging (78226). 
 
You asked the Plan to pre-approve the hepatobiliary system imaging. You say that the enrollee is still 
symptomatic with upper right quadrant pain, which is worse after eating. You also say that the enrollee had an 
ultrasound on July 29, 2021, that showed a fatty liver and possible cholecystitis, which indicates the need for 
this service. The Plan denied your request. The Plan says the records do not show that this service is needed for 
suspected gallbladder disease, suspected bile leak after trauma or surgery, a cyst or sac in the enrollee's bile 
duct, a pre-operative assessment for removal of a part of the enrollee's liver, chronic pain or swelling of the 
enrollee's gallbladder without stones, or the enrollee's gallbladder or related ducts and muscles do not work 
properly. 
 
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 hepatobiliary system imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no report of a July 29, 2021, ultrasound nor of elevated liver 
function tests that were provided to support there being radiographic features of cholecystitis. Our reviewer 
also found that further, available charting does not document right upper quadrant pain, only that the enrollee 
has unspecified stomach cramps without documentation of abdominal tenderness of Murphy's sign. Our 
physician reviewer also found that the medical necessity criteria are not met based on the provided records. 
 
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 hepatobiliary system imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hepatobiliary system imaging (78226).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual routine physical exam (99397) provided on July 2, 
2021. 
 
You asked the Plan to pay for an annual routine physical exam. You say that you did not know this was a 
physical. The Plan denied your request. The Plan says this exceeds the benefit limit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an annual 
wellness visit (AWV) once every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual routine physical exam (99397) provided 
on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
May 12, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 

We find that CPT code 99223 is not supported in the medical record. Specifically, medical records for this date 
of service were not provided to support the code billed. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care services coded 99223 provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electric Nerve Stimulation (TENS) unit on 
March 25, 2021. 
 
You asked the Plan to pay for the TENS unit. You say that the TENS unit should be covered. The Plan denied 
your request. The Plan says it is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS units and garments and supplies for 
chronic back/neck pain/radiculopathy are not a Medicare covered benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pay for 
Transcutaneous Electric Nerve Stimulation (TENS) unit on March 25, 2021.