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

 
We decided that the Plan does not have to pay for outpatient hospital services provided on May 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services were provided to the 
enrollee out of medical necessity, and you would like the claim to be paid. The Plan denied your request. The 
Plan says the rendering and referring provider are both out-of-network providers and there was no approved 
authorization. Also, the services provided was not urgent or emergent. 
 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 outpatient hospital services provided on May 7, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on July 27, 
2021, to September 27, 2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you cannot afford this charge 
and that it should be waived. The Plan denied your request. The Plan says the coinsurance amount charged is 
correct. 
 
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 10% 
coinsurance for all other Medicare-covered DME. Covered items include but are not limited to: oxygen 
equipment.  
 You have been asked to pay a total of $43.11 (The Plans allowed amount for each date of service is $143.69, 
10% of that allowed amount is $14.37. Therefore, three dates of service is $43.11 ($14.37 x 3 = $43.11). 
Oxygen equipment falls within the Durable Medical Equipment (DME) and Related 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 oxygen equipment provided on July 27, 2021, to 
September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EpiFix Allograft (CPT code Q4186). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Epifix wound care procedure is considered experimental or investigational per the 
health plan's medical policies and the evidence is insufficient to determine the effects of this technology on 
health outcomes. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found on March 14, 2022, the enrollee's wound measured 0.7 x 0.9 x 0.3 cm, however, there was no 
provided documentation of a prior measurement to compare and to evaluate whether the wound was improving 
or not with current conservative treatments. Therefore, without sufficient support made in the documentation, 
this request for Epifix graft will be considered not medically necessary at this time. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve EpiFix Allograft (CPT code Q4186).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 were admitted for 
cellulitis of the lower leg and squamous cell cancer of the ear canal. 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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (64438). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee is due for another injection. You also 
say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the 
requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) sessions 
per spinal region in a rolling twelve (12) month period. 
 
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 injection. Our reviewer says that the 
requested epidural steroid injection (ESI) is not medically necessary. Our physician reviewer found ESI's are 
limited to a maximum of 4 sessions per spinal region in a rolling 12 month period. The reviewer found that the 
enrollee has had 4 lumbar epidural steroid injections since May 19, 2021. The reviewer found that additional 
injections are not indicated at this time. Therefore, the reviewer found that the requested ESI is not medically 
reasonable or necessary at this time. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injection (64438).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria (J1602). 
 
You asked the Plan to pre-approve Simponi Aria. You say that Simponi Aria is medically necessary. The Plan 
denied your request. The Plan says a trial of Inflectra or Renflexis is required before alternatives can be 
considered. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Simponi Aria. Our reviewer says that 
Simponi Aria is not medically necessary. Our physician reviewer found the record does not show a trial of the 
plan preferred drugs or any reason they would be unsafe or ineffective for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria (J1602).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0005) and accessories (E2617, 
E2609, E2231). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says the facility in which the enrollee resides does not meet 
the Medicare definition of a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0005) and accessories 
(E2617, E2609, E2231).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
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 
service is medically necessary. Our physician reviewer found you do not require skilled nursing services. You 
do require continued skilled therapy services. The documentation supports that it is medically reasonable to 
provide skilled services on a daily basis on an inpatient basis, in a skilled nursing facility setting, as you are 
functioning well below your baseline, and have potential to improve. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. Daily skilled services are not 
required. You are walking household distances with a wheeled walker and you are stand-by assist for transfers. 
The wound care is reported to require three times per week care. You do not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the home 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) additional physical therapy (PT) visits 
(97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested 7 therapy visits are generally not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
enrollee has had prior therapy and the documentation does not reveal that he requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be able to 
transition to an independent home exercise program with the already approved therapy. The requested services 
are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve seven (7) additional physical therapy (PT) visits (97110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel provided on October 8, 
2021. 
 
You asked the Plan to pay for the definitive drug testing. You say that this testing was medically necessary for 
the treating physician. The Plan denied your request. The Plan says the documentation does not support the 
need for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing may be reasonable and 
necessary when it is individualized based on clinical history and risk assessment which must be documented in 
the record. 
 
We looked at the file and Medicare rules. No records from the ordering provider were submitted to show that 
this testing was ordered due to individual clinical history and risk assessment. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive drug testing panel provided on October 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical and occupational therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no other skilled nursing requirements. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there are no 
records leading up to the home health certification on 1/1/22. As such, there are no records showing any skilled 
nursing needs at that time. Subsequent records and events are unrelated to the issuance of the Notice of Denial 
of Medical Services (NDMC) on 1/3/2022. 
 
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 home health physical and occupational therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. You say that this medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Neulasta Onpro. Our reviewer says that 
Neulasta Onpro is not medically necessary. Our physician reviewer found use of this medication to treat your 
condition is not supported by Medicare approved compendium. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Neulasta Onpro.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
myelodysplastic syndrome with refractory anemia with ring sideroblasts. 3. The records do not document 
failure of an erythropoiesis stimulating agent or two or more red blood cell units over an 8-week period. 
Reblozyl is only approved for the treatment of anemia in patients with very low- to intermediate-risk 
myelodysplastic syndrome with ring sideroblasts or myelodysplastic syndrome/myeloproliferative neoplasm 
with ring sideroblasts and thrombocytosis who failed an erythropoiesis stimulating agent and require two or 
more red blood cell units over an 8-week period and for the treatment of anemia in patients with beta 
thalassemia who require regular red blood cell transfusions. Given that the criteria are not met, the Reblozyl is 
not reasonable or medically necessary and safe and effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit with a Neurosurgeon. 
 
You asked the Plan to pre-approve the office visit with a Neurosurgeon. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
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 office visit with a Neurosurgeon. 
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 evidence of severe spinal stenosis or any other indication 
for spinal surgery in the medical records or imaging study reports. 
 
 
 
 
 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 office visit with a Neurosurgeon have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the office visit with a Neurosurgeon.