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

 
We decided that the Plan does not have to pre-approve Cimerli Solution. 
 You asked the Plan to pre-approve Cimerli Solution. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Cimerli Solution. Our reviewer says 
that the documentation does not support that the requested drug meets step therapy criteria. Our physician 
reviewer found you have a diagnosis of exudative age-related macular degeneration. The documentation does 
not support that you have tried and failed bevacizumab (Avastin). The documentation does not support that 
bevacizumab (Avastin) would likely be less effective and/or likely have adverse effects. Therefore, you do not 
meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cimerli Solution have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Cimerli Solution.
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 the enrollee is unable to walk or stand 
and you believe it will take a longer time to recover. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that that the in-network providers only want to do 
shots and that is what caused a stroke so you would rather not have the shots. The Plan denied your request. 
The Plan says in most cases, the enrollees network primary care provider (PCP) must give the enrollee 
approval before they can use someone that is not their PCP or use other providers in the plans network. This is 
called a referral. If the enrollee does not get approval, the plan may not cover the services. The enrollee does 
not need a referral for certain specialists, such as womens health specialists. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you need to better delineate the source of the 
enrollee's cognitive disorders. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is noted to have a cognitive 
impairment. The notes suggest that the neuropsychology evaluation suggested Alzheimer's Dementia. There 
was no indication that the enrollee otherwise met diagnostic criteria for both AD and FTD. The rules for 
coverage are not met at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeSyle Libre 14 day sensor continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a FreeSyle Libre 14 day sensor continuous glucose monitor 
(CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional16 visits of physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records show that you have reached the expected level of improvement 
for your problems and more skilled treatment is not needed at this time.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had 10 sessions of physical therapy approved and by March 
27, 2023, you were noted to only be having discomfort with stairs and walking for long distances. You have 
improved by 60% and your motor strength and range of motion was nearly normal. While you may continue to 
have some pain, you are independent with mobility and performing daily activities. Your motor strength and 
range of motion have stayed essentially the same. You can manage your pain with a home exercise program. 
The services of a skilled therapist are not needed. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional16 visits of physical therapy (PT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on December 29, 2022. 
 
  You asked the Plan to pay for initial hospital care (99223). You say that the medical records illustrate the need 
for the services rendered. You say that this claim is for an inpatient physician and the decision should be 
reassessed. The Plan denied your request. The Plan says it is not appropriate to report this service with POS 21 
when the claim history shows the enrollee was registered in outpatient hospital observation status for this date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the enrollee was in 
outpatient observation on this date of service, but the inpatient POS code was billed. Based on this information, 
we decided that Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital care (99223) provided on December 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 5 home physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the medical records submitted support 
the medical necessity for home health physical therapy visits. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
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 enrollee 
does not have documented, ongoing home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are not medically necessary or reasonable. 
 
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 an additional 5 home physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unspecified adjunctive procedure, by 
report (D9999) provided on January 21, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the unspecified adjunctive procedure, by report (D9999) provided on January 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (excluding final 
restoration) (D3330), endodontic therapy, premolar tooth (excluding final restoration) (D3320), and endodontic 
therapy, anterior tooth (excluding final restoration) (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that you have not found a dentist that will take 
your in-network insurance. You also say that you have tried 4 places. The Plan denied your request. The Plan 
says dental services from an out-of-network provider are not covered by your supplemental benefits. The Plan 
Provider Directory shows there are 15 in-network providers within a 50 miles radius of your zip code. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy, molar tooth (excluding final restoration) (D3330), endodontic therapy, premolar tooth (excluding final 
restoration) (D3320), and endodontic therapy, anterior tooth (excluding final restoration) (D3310).
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 need intensive rehabilitation and don't want to 
lose mobility. You say you have weakness and are a fall risk. 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 that your 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary closure of a sinus perforation and placement 
of intra-socket biological dressing (D7261, D7922). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
primary closure of a sinus perforation and placement of intra-socket biological dressing (D7261, D7922).
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Venofer (iron sucrose). The documentation does not support that Venofer (iron sucrose) would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
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: 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 appeal for the denial 
of an IRF admission. 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 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: 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 you feel the IRF services would be beneficial for the 
enrollee. You also say the enrollee needs physical therapy to regain strength. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 enrollee's 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 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.