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

 
We decided that the Plan does not have to pre-approve the Prolia injection. 
 
You asked the Plan to pre-approve the Prolia. You say that that the enrollee has had long term corticosteriod 
usage. You also say that the enrollee has a history of borderline low calcium making her not a great candidate 
for bisphosphonate therapy. The Plan denied your request. The Plan says the provided documentation does not 
support a diagnosis of osteoporosis. The Plan also says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug is not medically necessary Our physician reviewer found that the Local Coverage Article 
(A52399) guidelines state that Prolia is for patients with postmenopausal osteoporosis at high risk for fracture.  
 
 
 
 
The reviewer found that the enrollee does not have a diagnosis of osteoporosis, but rather has osteopenia, based 
on a Dexa scan on September 17, 2020. The reviewer also found that the documentation does not support that 
the requested injection would be safe and effective for the enrollee. Therefore, the reviewer found that the 
requested drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Prolia injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one (J7325). 
 
You asked the Plan to pre-approve Synvisc-one. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 the 
criteria for Synvisc-one have not been met. Our physician reviewer found there is no documentation of failure 
of Orthovisc or Monovisc treatment. Our reviewer also found that recent literature shows Synvisc does not 
work well in enrollees with knee degenerative joint disease. 
 
 
 
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 (J7325).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 patient appears to be gradually improving but requires only short-term acute care 
services of less than 25 days based on recent documentation. The patient does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer to a lower level of care may be 
considered soon when more appropriate. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be safely and better managed in a less 
restrictive setting. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections 
(TFESIs). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic low back pain. You 
previously had epidural steroid injections with little relief of your pain. Given that you did not receive 
significant relief from the prior injections, repeat injections are 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 repeat transforaminal epidural steroid injections (TFESIs).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that physical therapy is helping 
you stretch and relieve back pain. You say that physical therapy helps keep you stable and your muscles strong. 
The Plan denied your request. The Plan says additional visits are 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 pre-approve 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 unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TP 53 genetic testing. 
 
You asked the Plan to pre-approve TP 53 genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The TP 53 genetic testing at issue in this appeal is being requested solely for screening purposes. The 
documentation does not support how this testing would change the treatment of the enrollees already 
diagnosed condition. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pre-approve TP 53 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99215) to be provided by a 
tertiary level out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that you see this doctor every 7 to 8 
months due to issues with your liver. You trust this doctor and want to continue seeing her. The Plan denied 
your request. The Plan says office visit with a tertiary level hepatologist is not medically necessary. The plan 
has instead approved for the enrollee to see a community hepatology specialist. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 outpatient office visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation does not outline a rationale for referral to this center.  An in-network 
hepatology specialty visit has been approved. Without support of documentation, referral to the tertiary center 
is not determined 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 outpatient office visit have not been met.  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 the outpatient office visit. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient office visit (99215) to be provided by a tertiary level out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home personal care services. 
 
You asked the Plan to pre-approve the home personal care services. The Plan denied your request. The Plan 
says home personal care is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. The Plan contract says that personal care 
services are not covered by Medicare. 
 
We looked at the file, the Medicare rules and the Plan's rules. The file shows that you do not meet the 
Medicare coverage criteria for a HHA. The file shows the Plan does not cover personal care services per 
Medicare. Therefore, we decided that the Plan does not have to pre-approve home personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14. 
 
You asked the Plan to pre-approve the crown. You say that the enrollee refused to have tooth #14 extracted. 
You also say that tooth #14 will serve as a pillar for an upper partial denture. The Plan denied your request. The 
Plan says tooth #14 has a clinically unacceptable root canal fill. The Plan also says that placing a crown on 
tooth #14 in its current state is not recommended. 
 
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 the crown 
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 the crown. Our reviewer says that the 
crown for tooth #14 is not medically reasonable and necessary. Our physician reviewer found due to the 
unaddressed issues with tooth #14 (incomplete root canal and periodontal disease) making the prognosis poor, 
the criteria for coverage for a crown have not been met. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you lost your previous denture. 
The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also 
says that you had this service less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a mandibular partial denture on July 3, 2018, and your mandibular 
denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair seat cushion (E2607) and handles 
(K0108). 
 
You asked the Plan to pre-approve the wheelchair seat cushion and handles. You say that the accessories are 
medically necessary. The Plan denied your request. The Plan says rules for coverage for these items are not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that seating cushions are covered when medically 
necessary. Items that do not serve a Medical purpose are not covered.  
 
We looked at the file and Medicare rules. The provided medical records do not document any pressure ulcer 
that would meet the coverage criteria for the seating cushion. The requested 8-degree bend push handles are a 
custom upgrade and not considered primarily medical in nature and are not covered. Based on this information, 
we decided that Medicare rules for coverage of the wheelchair seat cushion and handles have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair seat cushion (E2607) and 
handles (K0108).
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 the enrollee needs to be moved to the IRF floor due 
to his acute medical needs. The Plan denied your request. The Plan says the enrollee does not meet functional 
criteria for admission to a rehab unit. 
 
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 that the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee's medical condition has stabilized, and the documentation does not support that 
his medical issues require acute rehab nursing care, or monitoring by an inpatient PM+R physician three times 
per week. While the enrollee is reasonably expected to benefit from continued physical therapy and 
occupational therapy, the documentation does not support that there is need for an intensive therapy program 
with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to 
rehabilitation 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of bone in lower jaw (21025), a surgical 
extraction (D7210), and the removal of an impacted tooth (D7240). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. You say that you 
have diabetes and as well as multiple medical conditions. The Plan denied your request. The Plan says the 
services you are requesting are dental in nature. The Plan says that the requested services are not in preparation 
for radiation, nor due to problems with your jaw or a tumor. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the excision of bone in 
lower jaw (21025), a surgical extraction (D7210), and the removal of an impacted tooth (D7240).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health shift nurse (T1030). 
 
You asked the Plan to pre-approve the home health shift nurse. You say that this service 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 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 looked at the file and Medicare rules. The requested service is not considered a skilled service and is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the home health 
shift nurse have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health 
shift nurse (T1030).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two alveoloplasties in conjunction with extractions and 
three extractions. 
 
You asked the Plan to pre-approve the alveoloplasties and extractions. You say that you need these services, 
and also need help paying for them. The Plan denied your request. The Plan says alveoloplasty in conjunction 
with extractions is not a covered benefit. The Plan also says that your extractions benefit has been exhausted 
for the 2020 plan year. 
 
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, alveoloplasty in conjunction with 
extractions is not among those covered under this benefit. The contract clearly states that extractions are limited 
to two procedures per calendar year. The record shows that you were approved for two extractions on June 8, 
2020 and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve two alveoloplasties in conjunction with extractions and three extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient office visit with code 99203 provided on June 
3, 2020. 
 
You asked the Plan to pay for new patient office visit. You say that the enrollee does qualify as a new patient 
with this provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the enrollee received an evaluation and management (E/M) or other face-to-face service from this 
physician group practice and same physician specialty on January 14, 2020, therefore a new patient visit code 
is not appropriate for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for the purposes of E/M visit codes, a 'new 
patient' is a patient who has not received any professional services or other face-to-face services from the 
physician or physician group practice (same physician specialty) within the previous 3 years.  
 
We looked at the file and Medicare rules. The enrollee received a face-to-face service from the same physician 
group practice and physician specialty on January 14, 2020, therefore a new patient visit code is not appropriate 
for this claim. Based on this information, we decided that Medicare rules for coverage of new patient office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit 
with code 99203 provided on June 3, 2020.