Persius/hicric huggingface dataset:
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 you are requesting an expedited reconsideration 
for the denial of an IRF admission. You say the enrollee is medically complex and needs to go to acute 
rehabilitation to regain the necessary strength to be able to complete activities of daily living and to get home.  
The Plan denied your request. The Plan says the IRF services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee is very angry the Plan has denied the 
requested drug. The Plan denied your request. The Plan says that the enrollee does not meet the Part B Step 
Therapy requirements for Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
enrollee does not meet the criteria for the requested drug, Prolia. Our physician reviewer found the Plan 
requires a trial of both oral and IV bisphosphonates before they will approve the requested drug. The enrollee 
has not tried and failed the required drugs. There is no documentation provided indicating that the plans 
required drugs would likely be less effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional routine transportation miles.. You say that you do not have 
any other transportation available. The Plan denied your request. The Plan says you are requesting an 
additional 9 miles for a total of 59 miles and your benefit only allows 50 miles. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 59 miles. 
Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation miles.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you are scheduled for this infusion. The Plan denied 
your request. The Plan says the Plan requires a trial of Ferrlecit, Infed, or Venofer before it will approve 
Feraheme. 
 
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 Feraheme. Our reviewer says that you 
do not meet criteria for a step therapy exception for Feraheme. Our physician reviewer found you have not tried 
and failed the Plan's drugs of Ferrlecit, Infed, or Venofer. The record does not show that these drugs would 
likely be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided and the guidelines of the National 
Comprehensive Cancer Network (NCCN) there is no documentation that the electronic brachytherapy at issue 
in this case meets all Medicare criteria for medically reasonable and 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on December 28, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that the services should be covered. 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 a rest home visit 
provided on December 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not 
meet the requirements for approval. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The clinical documentation shows that the enrollee requires ongoing skilled services but 
does not show that they are required daily. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift system (E1399). 
 
You asked the Plan to pre-approve a stair lift system. You say that you need a stair lift/elevation system 
because you are unable to get up the stairs to the second floor of your home. The Plan denied your request. The 
Plan says a stair lift system is not covered by the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift system (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2022, to 
August 1, 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 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code J18.9, described as 
Pneumonia, unspecified organism. 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee presented with shortness of breath and a known deep vein 
thrombosis. She was found to have a pulmonary embolism and lymphadenopathy that was concerning for 
malignancy. While the enrollee was treated for possible pneumonia, the enrollee was afebrile and did not have 
leukocytosis. As such, the billing of J18.9 is not supported.  
 
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 July 21, 2022, to August 1, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the technetium tc-99m mertiatide injection 
provided on December 6, 2022, by an in-network provider. 
 
You asked the Plan to waive the deductible for the injection. You say that you think that the deductible is too 
high. 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. Your 
contract with the Plan says that you must pay the full cost for most covered services, until you have paid the 
$246 deductible, and the deductible applies to the injection. 
 
 
 
 
 You have been asked to pay a $222.30 deductible for the injection. The item or service you asked the Plan to 
waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $246 
deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing 
is a contractual obligation that had not been met at the time the injection was received on December 6, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the technetium tc-99m mertiatide 
injection provided on December 6, 2022, by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home visit provided on January 26, 2023. 
 
You asked the Plan to pay for an at home visit. You say that this was medically necessary and should be 
covered. 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 an at home visit 
provided on January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve implantation of a CardioMEMS device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 implantation of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral waterjet ablation procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the prostate volume was re-measured at 
31.4 cc's.  The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that water vapor thermal therapy is only covered under 
certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has benign prostatic hyperplasia with lower urinary tract symptoms. The 
enrollee has a prostate size of 31.4 cc and a AUA score is 26. He has been on maximal medical therapy with 
tamsulosin and dutasteride. This request is for a Rezum procedure. The clinical documentation did not provide 
his maximum urinary flow rate, or what medical conditions, if any that, make him a poor surgical candidate for 
other surgical interventions. Therefore, the request 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transurethral waterjet ablation procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested testing is medically necessary. 
The Plan denied your request. The Plan says the requested test does not meet the Medicare requirement. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, per Medicare, the requested genetic testing is not 
covered unless the enrollee is pregnant. There is no documentation to show the enrollee is pregnant. Therefore, 
we decided that the Plan does not have to pre-approve genetic testing (81240, 81241).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy (MNT) is covered by 
Medicare only for diabetes and renal disease 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says Medicare does not 
cover ventilators for the requested use.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. The home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with average volume assured pressure 
support (AVAPS) and a back-up rate. The records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. Ventilators used to provide BiPAP therapy are not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 8, 2021, to 
April 11, 2021, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code J96.01, described as acute 
respiratory failure with hypoxia. 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee presented with shortness of breath, cough and 
malaise. She was known to have an elevated white blood cell count and found to have radiographic pneumonia. 
She was provided with antibiotics and supplemental oxygen. Mild hypoxia is expected with pneumonia. There 
is no evidence that the enrollee had respiratory failure or frank hypoxia. As such, the billing of J96.01 is not 
supported.  
 
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 April 8, 2021, to April 11, 2021, at the Diagnosis Related Group 
(DRG) originally billed.