Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the drug is necessary for the treatment of the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Venofer. 
 
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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Venofer. The reviewer also found that there is 
no documentation provided indicating that the plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 13, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately billable. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on February 13, 2023.
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 meets the full criteria for IRF services. 
The Plan denied your request. The Plan says the enrollee's records do not show that you need an intensive team 
for your care. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on February 20, 
2023. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you should only have a $25 
urgent care copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $35 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the specialist 
physician/practitioner services 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. The record shows the services were received and billed by an outpatient clinic. 
Therefore, we decided that the Plan does not have to reduce the copayment for the office visit provided on 
February 20, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan.  
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied 
your request. The Plan says a trial of Durolane, Euflexxa, Supartz, and GelSYN-3 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Graves' disease with 
orbitopathy. She has not tried and failed the Plan's required drug, a high dose oral steroid. The records do not 
show that the required drug would be contraindicated or less effective; therefore, Tepezza is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tepezza.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code(s) 88305. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 20, 
2023.
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 it is not safe to release you home. The Plan denied 
your request. The Plan says your records do not show that you are able to take part in 3 hours of therapy a day 
at least 5 days a week or 15 hours per week. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted ambulance services (A0999) billed for date of 
service April 13, 2023. 
 
You asked the Plan to pay for procedure code A0999. You say that the services at issue were a necessity for 
your care. The Plan denied your request. The Plan says the billed code is a statutory exclusion. 
 
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 code A0999 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A0999 is a statutory exclusion. Based on this information, we decided that Medicare rules for coverage of procedure code A0999 have not been met. Therefore, we decided that the Plan does not have to 
pay for unlisted ambulance services (A0999) billed for date of service April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical needs will not be adequately 
met or managed in a skilled nursing facility level of care, nor will they receive adequate amounts of therapy 
needed to care for themself safely and efficiently at home.  The Plan denied your request. The Plan says 
admission to an IRF 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While enrollee may have a need for physical therapy 
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 the enrollee 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99232 billed for date of service January 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that the providers were different specialties. The 
Plan denied your request. The Plan says that an appropriate modifier was not billed. 
 
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. 
 
We looked at the file and the rules. We find that for code pair 99232 and 99238, there is a PTP modifier 
indicator of 1 when the provider type is a hospital. However, the claim is a physician claim. Also, the medical 
records show that code 99232 and 99238 were provided by two separate physicians. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for procedure code 99232 billed for date of service 
January 18, 2023.  
 
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 pay for inpatient hospital services provided on October 19, 2022 to 
October 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
service was properly billed. The Plan denied your request. The Plan says DRG 193 more accurately describes 
the service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 services at the DRG originally billed. Our reviewer says 
that DRG 871 is not supported by the provided records. Our physician reviewer found Sepsis was listed as a 
diagnosis for this admission, however, there was insufficient evidence of this diagnosis as the patient did not 
meet Sepsis criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 19, 2022 to October 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or computed tomography (CT)); lumbar or sacral (64636, 
64635).  
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s). You say 
that the enrollee would benefit from this procedure.  The Plan denied your request. The Plan says there were no 
lumbar magnetic resonance imaging (MRI), or CT findings provided for review to rule out soft tissues causes 
of the enrolle's pain, such as disc herniation, infection, or tumor  
 
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation 
of advanced imaging (CT scan or MRI). Therefore, the request is deemed not medically reasonable and 
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 destruction by neurolytic agent, paravertebral facet joint nerve(s) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or computed tomography (CT)); lumbar 
or sacral (64636, 64635).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that the enrollee lives many miles from the treatment 
center where chemotherapy is administered. You say that the Neulesta Onpro would prevent the enrollee from 
having to travel a long distance after the initial day of treatment. You also say that this would be much easier 
for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred 
drugs, Fulphila, Udenyca, Ziextenzo, or Nyvepria. 
 
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 Neulasta. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Fulphila, Udenyca, Ziextenzo, or Nyvepria. 
The reviewer also found that there is no documentation provided indicating that the Plan's required drugs 
would be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that 
the step therapy 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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show acute and comorbid conditions 
that likely will require prolonged hospitalization. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: 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 your care needs cannot be met at a lower 
level of care and your health will decline if a LTACH admission is denied The Plan denied your request. The 
Plan says the request is 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.