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

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 
You asked the Plan to pre-approve the Prolia. You say that it is felt that this treatment is medically necessary. 
The Plan denied your request. The Plan says there has been no trial of the preferred drug as required by Plan 
policy. 
 
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 the Prolia. Our reviewer says that the 
requested use of Prolia is not considered medically reasonable and necessary based on step therapy rules. Our 
physician reviewer found this patient with recurrent urothelial carcinoma and osteoporosis is requesting 
coverage for Xgeva (denosumab). The health plan requires a trial of zoledronic acid, which the patient has not 
 
 
yet had, or rationale that the use of zoledronic acid would be less effective. Neither of these criteria have been 
met. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (denosumab) injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips of 47 miles. 
 
You asked the Plan to pre-approve the trips of the requested length. You say that this should be covered as you 
are no longer able to drive. You do not feel that you should be able to get treatment just because it is more than 
30 miles away and the plan did cover these trips over the summer. The Plan denied your request. The Plan says 
your benefit does not cover trips over 30 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 Plan?s coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 30 miles. 
 
We looked at your request, the records in the case file, and the rules. You are asking for coverage of a trip that 
exceeds 30 miles. Based on this information, we decided that the Plan?s rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine 
transportation trips of 47 miles.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 7.5 mg Leuprolide acetate (J9217x4) provided on April 2, 
2020. 
 
You asked the Plan to pay for the 7.5 mg Leuprolide acetate. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 7.5 mg Leuprolide acetate. Our reviewer says that 4 units 
of J9217 do not meet criteria for billing or reimbursement criteria. Our reviewer found the documentation 
states,  "Leuprolide Acetate 22.5 mg every 3 months." J9217 Leuprolide Acetate 7.5 mg x 3 equals 22.5 mg, 
therefore, documentation supports 3 units. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 7.5 mg Leuprolide acetate have not been met. Therefore, we decided that the 
Plan does not have to pay for 7.5 mg Leuprolide acetate (J9217x4) provided on April 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. The Plan 
contacted the provider's office and were advised that you only went one for adjustments; however, the office is 
willing to assist you with your current dentures. 
 
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 exhausted your benefit frequency limit, because you had this service on January 28, 2020. Your EOC 
states that complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every 
five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one 
lower partial denture every five years, including routine post-delivery care). Therefore, we decided that the 
Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shingrix vaccine. 
 
You asked the Plan to pre-approve a Shingrix vaccine. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a Shingrix vaccine is not covered under the enrollee's 
Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Shingrix vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Shingrix vaccine. 
Therefore, we decided that the Plan does not have to pre-approve a Shingrix vaccine.  
 
Benefits for a Shingrix vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that the enrollee needs therapy.The Plan denied your request. The Plan says the admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed aboveare 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 12, 2020 and is medically stable. She is oriented to self only and requires minimal assistance with transfers and ambulation. She is able to ambulate short distances with a gait belt and two people. She requires assistance and set up for most activities of daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits (99201) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visits to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.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-approveoffice visits (99201) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the thromboendarterectomy (35351) provided on May 5, 2020. 
 
You asked the Plan to pay for the thromboendarterectomy. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that the documentation submitted did 
not support the service billed. 
 
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 35351 is thromboendarterectomy, including patch graft, 
if performed; iliac. 
 
We asked our coder 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 thromboendarterectomy. Our reviewer says that CPT 
code 35351 meets criteria for billing and reimbursement consideration. Our reviewer found the operative report 
documents that a Iliac Thromboendartectomy was attempted twice during procedure without satisfactory 
arterial inflow, and elected to proceed with a femoral-femoral bypass. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the thromboendarterectomy have been met. Therefore, we decided that the Plan 
has to pay for the thromboendarterectomy (35351) provided on May 5, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs to 
continue treatment as he is at high risk for relapse if released. The Plan denied your request. The Plan says that 
the enrollee can be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. The enrollee can be treated in a lesser restrictive setting as he is not showing any suicidal 
or homicidal ideation, auditory or visual hallucinations, delusions and is not showing any behaviors or 
aggression, being cooperative and compliant while not showing any acute threats to safety. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses. 
 
You asked the Plan to pre-approve eyeglasses. You say that the requested items are necessary. The Plan denied 
your request. The Plan says the amount requested exceeds the allowed benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 allowance for supplemental eyewear each year. Members are responsible for 
all costs over and above the allowance amount. 
 
We looked at the file and the Plan's rules. Specifically, the total cost for the requested eyeglasses is $579. This 
amount exceeds the allowed benefit. Based on this information, we decided that the Plan's rules for coverage of 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of neurostimulators (spinal cord 
stimulation). 
 
You asked the Plan to pre-approve spinal cord stimulation. You say that the enrollee is a suitable candidate for 
surgery and has specific factors that indicate they may benefit from this treatment. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the records do not show 
pain relief with a temporarily implanted electrode (trial), the enrollee has not had clearance from a 
psychologist/psychiatrist, and the enrollee does not have a covered diagnosis. 
 
The Plan follows Medicare rules. Medicare rules state that implantation of spinal cord stimulators is covered 
only when all of the above clinical criteria have been met. 
 
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 spinal cord stimulation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested spinal cord stimulators. Our 
physician reviewer found the enrollee does not have an evidence-based indication of a spinal cord stimulator 
trial. He has not had a formal psychiatric or psychological evaluation. Therefore, this 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 spinal cord stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of neurostimulators (spinal cord stimulation).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that 
the required drugs would be less effective or contraindicated; therefore, the Synvisc-One is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you just had surgery on your leg and do not have the mobility to be sent home. You need 24-hour care since you are not able to walk.The Plan denied your request. The Plan says therecords do not show that you need evaluations by a rehab doctor, nor do they show that you need to take part 3 hours daily for 5 days a week.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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was residing in a skilled nursing facility receiving care related to a broken ankle when he was admitted for vomiting. He had esophageal dilation. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. There is not 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.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 nothave to pre-approveacute 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 retainer crown and pontic for a fixed bridge (D6740 and D6245) as well as bone grafting for tooth space #30 (D6140).

You asked the Plan to pre-approve the fixed bridge with bone grafting. You say that you believe that these services are necessary and that this provider is in-network. The Plan denied your request. The Plan says it was found this provider is in-network and the extraction procedure was approved. However, the remaining services are not covered under your benefit.

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.

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 retainer crown and pontic for a fixed bridge (D6740 and D6245) as well as bone grafting for tooth space #30 (D6140).
Appeal type: Other
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no recent evaluation documenting recurrent symptoms or findings suspecting recurrent disease.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 scan.Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found n this enrollee with 2 separate and unrelated primary tumors the need for close surveillance is clear. In the letter of appeal the oncologist points out that this enrollee is at high risk for recurrent endometrial cancer since the original tumor was greater than 2 cm in diameter and had greater than 50% myometrial invasion at pathology. The clinician has provided the rationale for the request and has submitted supporting NCCN guidelines.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the abdomen and pelvis for the enrollee.