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

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the requested Udenyca is medically necessary. The 
Plan denied your request. The Plan says the requested Udenyca 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 Udenyca. Our reviewer says that the 
requested Udenyca is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of agranulocytosis in the setting of autoimmune induced myelofibrosis. The Food and 
Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot 
be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reaching/grabbing device, any type, any length 
(A9281). 
 
You asked the Plan to pre-approve reaching/grabbing device. You say that you need the reacher because you 
have really bad arthritis in your shoulders and hands. You drop a lot of things on the floor and if you did not 
have the reacher you would not be able to pick them up. The Plan denied your request. The Plan says this 
device is not a covered benefit under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reaching/grabbing device, any type, any length (A9281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the enrollee is not diabetic and is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Libre.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 Injectafer. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record does not indicate that you have 
a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasonic guidance for needle placement provided on October 27, 
2021, billed as a global service at an ambulatory surgical center (ASC) using code 76942. 
 
You asked the Plan to pay for the global service for ultrasonic guidance for needle placement. You say that no 
modifier is required for use of this ultrasound machine as it is owned not by the ASC but rather by the provider 
doing the anesthesia. As such, both the professional and technical components are payable. The Plan denied 
your request. The Plan says that since this was provided in a facility, only the PC is payable, and this should be 
billed with modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that while carriers may not pay for the TC of 
radiology services provided to hospital patients, they are required to pay the TC when provided to non-hospital 
patients.  
 
In this case, although an ASC is considered a facility setting, the payment for the TC radiology services is not 
included in the payment to this facility. As per the cited rules, the TC must be paid for services received in a 
physician's office, a freestanding imaging or radiation oncology center, or other setting that is not part of a 
hospital. Therefore, we decided that the Plan has to pay for the ultrasonic guidance for needle placement 
provided on October 27, 2021, billed as a global service at an ambulatory surgical center (ASC) using code 
76942.  
 
 
 
 
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 (prothrombin,coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5(coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241). 
 You asked the Plan to pre-approve the F2 and F5 gene analysis. You say that you would like reconsideration 
because the enrollee is preparing for surgery and has a family history of blood clots. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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 F2 and F5 gene analysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has no history of deep vein thrombosis. The review has 
determined that the enrollee does not have a covered indication for testing. 
 
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 F2 and F5 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the F2 (prothrombin,coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5(coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough scientific evidence that this procedure is effective. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these devices remain experimental. More research is needed to show safety and efficacy. 
 
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 insertion of an interlaminar/interspinous stabilization/distraction device for the enrollee.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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. The 
documentation does not support that the enrollee requires at least 3 hours a day / 5 days a week, or 15 hours 
over 7 consecutive days, of therapy services. While the enrollee may be able to fully participate in intensive 
rehabilitation therapy, the documentation does not support that an intensive rehabilitation therapy program is 
medically reasonable and necessary for the enrollee in this case. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does 
not support that you require at least 3 hours a day / 5 days a week, or 15 hours over 7 consecutive days, of 
therapy services. It is not clear that you are reasonably expected 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glassia to be rendered by an out-of-network (OON) 
facility. 
 
You asked the Plan to pre-approve Glassia. You say that you feel Glassia is medically necessary for the 
enrollee's medical condition. The Plan denied your request. The Plan says the request for Glassia, with an OON 
facility, is not medically necessary. The Plan also says that this procedure can be performed with a participating 
facility. 
 
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 Glassia. Our reviewer says that 
treatment with Glassia to be rendered by an OON provider is not medically necessary. Our physician reviewer 
found this patient has the MZ phenotype of alpha1-antitrypsin deficiency, which is associated with mild or no 
reduction in A1AT levels, and is generally not associated with emphysema progression. Our reviewer found 
that this is not an accepted indication for treatment with Glassia. The patient's level is only slightly below 
normal, and is considered sufficient to be protective. Our physician reviewer also found that although the 
patient is short of breath, and pulmonary function tests do show mild obstruction, there is no evidence of lung 
function decline. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Glassia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Glassia to be rendered by an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex procedure. 
 
You asked the Plan to pre-approve the Coflex procedure. You say that you would like reconsideration because 
this procedure is medically necessary. The Plan denied your request. The Plan says this device is 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Coflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental, and more research is needed to show its safety and 
efficacy. 
 
 
 
 
 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 Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Coflex procedure.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a study similar to the one requested has recently been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is necessary in order to evaluate the brain as an adjunct to the already performed magnetic 
resonance angiography (MRA). Our physician reviewer found that the lack of this study seems to have been a 
clerical error but the exam is indicated and should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and power standing 
feature for a wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature and power standing feature. You say that the 
enrollee requires this for quality of life. The Plan denied your request. The Plan says the denial of authorization 
for these components is correct, because these features are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power 
standing feature are not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature and power standing feature have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power seat elevation feature and power standing feature for a 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on December 7, 
2021. 
 
You asked the Plan to pay for the oral exam. You say that these were urgently needed services and should be 
covered. The Plan denied your request. The Plan says your dental benefit covers a maximum of two periodic 
oral exams per plan year. You had previous periodic exams provided and covered for April 19, 2021, and 
October 25, 2021. Therefore, the exam provided on the date in question exceeds the frequency limitations of 
your benefit and was denied correctly. 
 
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. The Plan can cover up to two 
routine periodic exams (D0120) per plan year. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the 
periodic oral exam is requested in a frequency that is not covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the periodic oral exam (D0120) provided on December 7, 2021.
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 the enrollee is not getting adequate therapy and 
requires IRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
IRF services 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that the enrollee requires at least 3 hours per day, 5 days a week, or 15 hours 
over 7 consecutive days of therapy services. While the enrollee may be able to fully participate in intensive 
rehabilitation therapy, the documentation does not support that an intensive rehabilitation therapy program is 
medically reasonable and necessary for the enrollee in this case. 
 
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.