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

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Evenity. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found you have taken Alendronate for 5 years and developed additional bone loss. You have had a
course of Forteo that was discontinued in 2017. You have had a low trauma rib fracture and vertebral
compression fractures. You take daily calcium and Vitamin D. Evenity is only approved for post-menopausal
osteoporosis, at high risk for fracture or failed or intolerant to other therapy and there is not support in
approved medical compendia for treating male osteoporosis. The documentation supports that you are a male
and not post-menopausal. 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require transfer
to a SNF at this time. Although he would benefit from observation and PICC line management it does not
appear that his medical status is optimized prior to transfer. His functional level does not require transfer to a
SNF at this time with skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee
continues to need supplemental oxygen and his creatinine was 1.06 on 7/4 and 1.05 on 7/19 and the most recent
labs documented creatinine is elevated at 1.31 on 7/21. His medical and rehabilitation status can be managed at
his current setting until he is stable for discharge. As a practical matter, the documentation does not support
that this enrollee requires skilled nursing or skilled therapy services on an inpatient basis, in a skilled nursing
facility setting 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 10 additional physical therapy visits.
You asked the Plan to pay for 10 additional physical therapy visits. You say that the enrollee would benefit
from additional physical therapy to address remaining functional deficits and return to pre-injury status. The
Plan denied your request. The Plan says the additional physical therapy is not medically necessary.
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 pay for 10 additional physical therapy 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 that the enrollee received extensive therapy and is
competent in a home exercise program. Our physician reviewer also found that the deficits do not require
ongoing skilled professional therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pay for 10 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a BluePrint test.
You asked the Plan to pre-approve the BluePrint test. You say that the requested testing is medically
necessary. The Plan denied your request. The Plan says the testing that remains in dispute is considered
statutorily excluded by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the BluePrint test is a statutorily excluded test.
Therefore, we decided that the Plan does not have to pre-approve a BluePrint test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of the StimWave peripheral nerve
stimulator for knee pain.
You asked the Plan to pre-approve the StimWave implantation. You say that you feel that this should be tried
since all other treatments have failed. The Plan denied your request. The Plan says peer-reviewed literature
does not support the effectiveness of this device.
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 StimWave implantation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee is a female with complex regional pain syndrome involving the
left knee. She has had Physical Therapy, Steroids, ice, rest, Tramadol trial, Tylenol and a Total knee
Replacement. She had a StimWave Percutaneous Electrical Nerve Stimulation trial and achieved 75% pain
relief. She has not had a Spinal Cord Stimulator or Intra-thecal pump trial.
The StimWave device is an experimental/ investigational device for the enrollee's syndrome. Therefore, the
request is considered 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 the StimWave implantation have not been met. Therefore, we decided that the
Plan does not have to pre-approve implantation of the StimWave peripheral nerve stimulator for knee pain.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says that the enrollee
has not met 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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically reasonable and necessary for the enrollee in this case. There is no evidence that
the enrollee is allergic to Orthovisc and Monovisc. There is no evidence that the enrollee has tried and not
responded to Orthovisc and Monovisc. There is no documentation as to why Orthovisc and Monovisc would
not be expected to be safe and effective for the enrollee. Our physician reviewer found that the enrollee's
condition does not meet step therapy criteria for Synvisc-One.
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-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says the enrollee's
medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Prednisone.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 27, 2020.
You asked the Plan to reimburse you for the hearing aids. You say that the Plan's audiologists were too far away from your home. You say this provider was closer. The Plan denied your request. The Plan says you must utilize a provider in the Plan's vendor network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by a provider in the Plan's vendor network. We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an audiologist that is not in the Plan's vendor network. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 6, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The
Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient services provided on January 6, 2020 by
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox. You say that the botox is medically necessary. The Plan denied your
request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Botox. Our reviewer says that the botox
injections are not medically necessary. Our physician reviewer found the record shows the enrollee has had
good response to Myrbetiq for her overactive bladder symptoms. Based on lack of documentation of failure or
significant side effect of Myrbetriq the documentation does not support that the Botox is medically reasonable
and necessary for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because you are
unable to walk due to your condition. The Plan denied your request. The Plan says this item is not a covered
benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nulojix (J0485).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the use of this drugs requires that it will be used in combination with basiliximab
induction, and corticosteroids.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 services. Our reviewer says that the
requested drugs are not medically reasonable or necessary. Our physician reviewer found the enrollee is status
post a kidney transplant. She is noted to be EBV +. She has been on several different anti-rejection
medications. She is currently taking tacrolimus, mycophenolate, dapsone, methylprednisolone and
valganciclovir. A request has been made to start the enrollee on belatacept (Nulojix). Belatacept is intended for
use in combination with basiliximab induction, mycophenolate mofetil and corticosteroids in EBV + patients.
The documentation does not show that the enrollee is using or will receive basiliximab induction. As such, the
requested drug is not shown to be 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Nulojix (J0485).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from May 14,
2019 to October 29, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that the Plan should pay this claim.
The Plan denied your request. The Plan says infusion services are not allowed when billed by a nonparticipating
provider.
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 S9328 is home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare
uses another code for reporting of, and payment for, these services. Based on this information, we decided that
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided
that the Plan does not have to pay for the home infusion therapy services provided from May 14, 2019 to
October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee scooter (E0118).
You asked the Plan to pay for the knee scooter. You say that you would like reconsideration because you are
non-weight bearing due to a toe fracture. The Plan denied your request. The Plan says crutch substitutes are not
considered to be medically necessary or covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that 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 the knee scooter have not been met. Specifically, per the durable medical equipment Medicare
Administrative Contractor, medical directors have reviewed information about the products billed using this
code (E0118). The determination is that there is insufficient published clinical literature demonstrating safety
and effectiveness in the Medicare population to establish the medical necessity for these products. Therefore,
we decided that the Plan does not have to pay for a knee scooter (E0118).
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 please review attached clinicals for IP acute
rehabilitation admission. The Plan denied your request. The Plan says the enrollee could safely receive the
needed services in another setting such as a skilled nursing facility, home with home health services or home
with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 based on review of the available records, the enrollee does not meet criteria for IRF
admission. The enrollee is not medically stable with no evidence of need for supervision by physical therapy
and rehabilitation physician or need for acute rehab nursing care. The enrollee may benefit from further
physical therapy and an occupational therapy but does not require an intensive therapy program. IRF admission
is not medically appropriate based on the patient's current medical instability.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care provided from July 23, 2019 to
October 30, 2019.
You asked the Plan to pre-approve home health care. You say that these services should be covered. The Plan
denied your request. The Plan says you were not receiving skilled nursing or therapy services.
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 care. Our reviewer says
that the home health care at issue was not medically necessary. Our physician reviewer found the records do
not show that skilled nursing or skilled therapy services were required to effectively provide treatment, care,
and/or services in order to improve your condition or level of function, or to establish/perform a maintenance
program to maintain your level of function and/or prevent deterioration during the dates of services in question.
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 care have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health care provided from July 23, 2019 to October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown on tooth #19 (D2950, D2750).
You asked the Plan to pre-approve a crown on tooth #19. You say that you have had a toothache for 7 months.
The Plan denied your request. The Plan says that the tooth has extensive bone loss.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a crown on
tooth #19 when the services are medically necessary and reasonable.
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 crown on tooth #19. Our reviewer
says that the criteria for coverage of the requested crown have been met. Our physician reviewer found tooth #19
has adequate bone support and significant coronal breakdown. The requested crown is necessary to restore the
tooth to adequate function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a crown on tooth #19 have been met. Therefore, we decided that the Plan has to
pre-approve a crown on tooth #19 (D2950, D2750).
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.