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

 
We decided that the Plan does not have to pre-approve Synvisc or Synvisc-one (J7325).  
 You asked the Plan to pre-approve Synvisc or Synvisc-one (J7325). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says they asked the provider for information on 
why the requested drug is needed. The Plan also says they did not receive all of the necessary information to 
make a decision about paying for the requested drug.  
 
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 Synvisc or Synvisc-one (J7325). Our 
reviewer says that the enrollee does not meet the criteria for the requested service. Our physician reviewer 
found the patient has not tried and failed the required drug, Euflexxa. Our physician 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc or Synvisc-one (J7325) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Synvisc or Synvisc-one (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization (36247, 36246). 
 
You asked the Plan to pre-approve a genicular artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the procedure is considered experimental and investigational for the 
treatment of osteoarthritis-related knee pain. The review has determined that the items/services at issue in this 
case are 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 a genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular artery embolization (36247, 36246).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3.  You asked the Plan to pre-approve a Freestyle Libre 3. You say that the requested CGM is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 3. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. 
 
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 Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Health services with Physical Therapy visits.  
 You asked the Plan to pre-approve home health services. You say that you would like approval for physical 
therapy at home. The Plan denied your request. The Plan says you are not home-bound and do not need skilled 
physical therapy services on an individual basis. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not establish that the enrollee is home-bound nor hows a need for skilled nursing or skilled 
therapy visits.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Home Health services with Physical Therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 13, 
2023, to July 24, 2023. 
 You asked the Plan to pay for SNF care. You say that the services should be covered under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for skilled nursing facility (SNF) care provided from July 13, 2023, to July 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on July 25, 2023. 
 
You asked the Plan to pay for medical supplies. You say that there are payable to you separately from the 
skilled nursing facility (SNF) stay. The Plan denied your request. The Plan says the enrollee was not in an 
approved skilled nursing facility (SNF) stay at the time of service; therefore, the Place of Service (POS) code 
billed on this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 31 should be used 
for a beneficiary in a covered SNF stay and POS code 32 should be used for a beneficiary in a non-covered 
stay.  
 
We looked at the file and Medicare rules. This beneficiary was in a non-covered stay for this date of service; 
therefore, POS code 31 is not appropriate for this claim. Based on this information, we decided that Medicare 
rules for coverage of medical supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for medical supplies provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator. 
 
You asked the Plan to pre-approve a hypoglossal nerve stimulator. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
stimulator. 
 
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 hypoglossal nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that you have a history of OSA. To approve coverage 
for the stimulator, the medical records must show a BMI less than 35 and documented failure of nasal positive 
airway oxygen therapy and all alternatives for CPAP. In this case, your BMI is 37.1. The review has 
determined that you do not meet criteria for approval of the requested stimulator. 
 
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 hypoglossal nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hypoglossal nerve stimulator.
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's balance and stamina have been greatly 
reduced since having multiple procedures. You say that the enrollee would benefit from the level of care at an 
IRF and would be back to their normal life and routine in a short time. The Plan denied your request. The Plan 
says an IRF admission 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 waive the copayment for an acute inpatient stay provided on August 
22, 2023, to August 24, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you were stuck in the 
hallway with a privacy screen. This was not what you would call a private room. 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 $290 
copayment for inpatient hospital care.  
You have been asked to pay a $290 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $580 for the inpatient hospital stay ($290 copayment 
x 2 days = $580). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on August 22, 2023, to August 
24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heel loops (E0591) push handles (K0108) impact guard 
neoprene (K0108) poly-curved liner (K0108) gel calf support panel (K0108) and foam plate pads (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that this wheelchair is medically 
necessary to keep the enrollee safe as well as to help with transportation.  The Plan denied your request. The 
Plan says the heel loops, push handles, impact guard neoprene, poly curved liner, gel calf sup panel, and foam 
plate pads are not mainly used to serve a medical purpose.  
 
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 wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found per LCA A52504 and LCD L33792 the criteria has not been met as the 
enrollee does not have skin problems or spasticity. The neoprene guards and push handles do not serve a 
medical purpose. The additional padding is not medically necessary as the enrollee has intact skin and no 
evidence of spasticity or need for special positioning.  
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve heel loops (E0591) push handles (K0108) impact guard neoprene (K0108) 
poly-curved liner (K0108) gel calf support panel (K0108) and foam plate pads (K0108).
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 this is medically necessary. The Plan denied your 
request. The Plan says while you may benefit from ongoing physical and occupational therapy, the services you 
need can be provided safely in another setting, such as a skilled nursing facility (SNF) or home with home 
health. Under Medicare, the request 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 the patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF placement. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 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 the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. Medically necessary care can be provided in a different level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alprazolam. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 alprazolam.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the abdomen and 
pelvis (74176) provided on April 10, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says if no bilateral code is provided and the condition is bilateral, 
providers must assign separate codes for both the left and right side. When a patient has a bilateral condition 
and each aside is treated during separate encounters, assign the bilateral code, including for the encounter to 
treat the first side. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that the ICD-10-CM code for an unspecified side condition should only be used rarely in certain 
situations where the afflicted side cannot be determined. 
 
We find that the primary diagnosis code reported on this claim, C50.919 (malignant neoplasm of unspecified 
site of unspecified female breast), is not supported or appropriate in this case. Specifically, the records provided 
indicate that this issue is bilateral. This means that the bilateral ICD-10-CM code should be reported in this 
case. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been 
met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT scan) of the 
abdomen and pelvis (74176) provided on April 10, 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 fell, broke hip and had hip surgery, 
needing intense rehabilitation to be mobile. The Plan denied your request. The Plan says the enrollee's 
condition does not meet all the requirements for inpatient rehabilitation admission. The Plan says services may 
be provided at 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. The medical 
records support 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. It 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 acute inpatient rehabilitation facility (IRF) admission and services.