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

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred product. 
 
 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 Zilretta. Our physician reviewer found 
that you have osteoarthritis of the knee. The requested medication is not a new start. The provided records do 
not support the medical necessity and reasonableness of the requested service at this time. The elements of the 
coverage criteria 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99221) provided on May 6, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim was submitted 
upon receipt of corrected billing information from the enrollee. The Plan denied your request. The Plan says the 
claim was not submitted within one calendar year of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the evaluation and management service was not filed until May 13, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care (99221) provided on May 
6, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after September 8, 
2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that the continued SNF care is medically 
necessary. The Plan denied your request. The Plan says that the continued SNF care is not medically necessary. 
 
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 continued SNF care. Our reviewer says 
that the requested continued SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the documentation shows that the enrollee has wound care needs and 
requires medical assessment by a skilled nurse. Clinical documentation shows that the enrollee has complex 
functional impairments and is undergoing assistive device evaluation thus requires skilled therapy. The 
enrollees prior level of function was modified independent at a wheelchair level prior to hospitalization. From 
a practical standpoint, the enrollee continues to require daily services on an inpatient basis in 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 continued 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 
continued skilled nursing facility (SNF) care after September 8, 2022.  
 
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not require extensive or complex 
wound care management by skilled nursing of at least 6.5 hours per day. Additionally, the wound care does not 
require daily intervention by a physician. The clinical assessment does not support the expectation of a stay to 
be at least 25 days. The enrollee's medical needs are being met in the current acute setting. The LTACH would 
add no additional services. With additional time in the current setting, clinical stability can be ensured such that 
the appropriate lower level of care can be determined. 
 
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 that the enrollee has an acute condition that is currently being treated satisfactorily in 
an acute care setting and appears to be improving per clinical documentation with decreasing respiratory 
support and supplemental oxygen requirements thus the enrollee would not be expected to require LTACH 
services. Additional or other long term acute care services would not be expected to be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that you have tried and failed physical 
therapy and occupational therapy since you suffered a stroke in 2019. The requested device is medically 
necessary. The Plan denied your request. The Plan says a MyoPro is considered investigational due to the lack 
of clinical evidence demonstrating an impact on improved 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. Although records from the device manufacturer/vendor argue medical necessity of the requested 
device, no records from your actual treating provider clarify why the requested device is the most appropriate 
treatment for your condition. In addition, provided records report right upper extremity spasticity which may be 
a contraindication to use of the device. 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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
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 clinical documentation shows that the enrollee has complex medical issues 
which would benefit from close medical supervision, however evaluating therapists document that enrollee 
could receive post discharge therapy in a skilled nursing facility. Additionally, there is no specific mention of 
the enrollee's ability to tolerate three hours of therapy per day. Thus, IRF criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's status is critical. The enrollee is receiving 
medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on December 30, 2021. 
 
You asked the Plan to pay for the services provided. You say that the device is used in facility for the 
prevention of thrombotic events. The Plan denied your request. The Plan says there is insufficient evidence to 
justify reimbursement. 
 The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
In this case, the services at issue were provided at an ambulatory surgical center. The facility must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This service was provided via arrangement of the facility. Payment for this service would have been 
included under the facility claim. Payment to you for this service is the responsibility of the facility. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on December 30, 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 IRF care. You say that the longer the wait to approve authorization the less 
of a chance the enrollee has of making a full recovery. Please review the attached records for approval of 
inpatient rehabilitation approval. The Plan denied your request. The Plan says this request does not meet 
Medicare guidelines for medical necessity because the enrollees medical condition requires further evaluation 
and treatment in the acute care hospital. 
 
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 enrollee is chronically ill and severely deconditioned. The enrollee does not have 
capacity to participate in intensive rehabilitation. The physiatry note indicates on-going medical needs and does 
not address the enrollees very limited capacity. The primary reason for admission to an IRF is for intensive 
rehabilitation not as a destination for continued medical management. The enrollee's medical condition 
precludes reasonable participation in and benefit from intensive rehabilitation. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor 
(93228, 93229). 
 
You asked the Plan to pre-approve an MCOT monitor. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services at issue are 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 an MCOT monitor. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of palpitations. There is no evidence of an ambulatory 
Holter monitor having been performed. As such, guidelines would not support a need for MCOT monitoring in 
this 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 an MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor (93228, 93229).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles immunization (90750) provided on November 2, 
2020. 
 
You asked the Plan to pay for the immunization. You say that the shingles immunization should be covered per 
the policy. The Plan denied your request. The Plan says the shingles immunization is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that immunizations considered routine preventative 
immunizations or are not a disease entity endemic in the United States are not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the immunization have not been met. Therefore, we decided that the Plan does not have to pay for 
the shingles immunization (90750) provided on November 2, 2020.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Naked Prosthetics metacarpophalangeal (MCP) and 
proximal interphalangeal (PIP) partial finger prostheses with articulating digits. 
 
You asked the Plan to pre-approve the requested type of partial finger prostheses. You say that this is the only 
type of prosthesis that can meet the enrollees needs, and since there is no approved code for this type of 
prosthesis, the code L7499 is correct. The Plan denied your request. The Plan says this was originally denied as 
incorrect coding, but the Plan has also indicated that the requested items exceed the enrollees need. 
 
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 requested type of partial finger 
prostheses. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the requested device has not been shown to be superior to other 
standard treatments for the medical condition. There is no indication that the specific brand of prosthesis 
improves an individuals function or general health. The requested device is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested type of partial finger prostheses have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Naked Prosthetics metacarpophalangeal (MCP) and 
proximal interphalangeal (PIP) partial finger prostheses with articulating digits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test provided on August 17, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug test. You say that the services provided were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network and authorization is required prior to an out-
of-network visit. 
 
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 drug test provided on August 17, 2021, by an out-
of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, and S831 billed for date of 
service December 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that you provided the items at your own expense. 
The Plan denied your request. The Plan says the billed codes are invalid 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 procedure code. 
 We find that procedure codes A9279, S1015, and S831 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes A9279, S1015, and S831 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, S1015, and S831 
billed for date of service December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment; spinal (98941) and 
electrical stimulation (G0283) provided from March 2, 2022, to March 18, 2022. 
 
You asked the Plan to pay for chiropractic manipulative treatment and electrical stimulation. You say that the 
AT modifier shows medical necessity. The Plan denied your request. The Plan says chiropractic services and 
electrical stimulation is not a covered benefit because chiropractic manipulation is covered only for the 
treatment of subluxation, and no other services furnished by chiropractor are covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulative treatment; spinal (98941) and electrical stimulation 
(G0283) provided from March 2, 2022, to March 18, 2022.