Persius/hicric huggingface dataset:
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 is not medically 
necessary. 
 
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 there is no need for physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says scaling and root planing is covered once per quadrant every 3 years. The 
Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and scaling and root planing is listed as covered, the frequency limit of once every 3 years, per quadrant, had been reached. The record shows that the 
Plan paid for scaling and root planing for all 4 quadrants that you received on May 5, 2021. Therefore, we 
decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the enrollee needs this drug. 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 may pay for unlabeled uses for anti-cancer 
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 Imfinzi. Our reviewer says that the 
requested drug, Imfinzi, is not medically necessary. Our physician reviewer found the requested drug is being 
requested as initial single agent treatment for the noted diagnosis. The Food and Drug Administration (FDA) 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation.  No literature from Medicare approved cancer journals were submitted for review. Therefore, the 
reviewer found that the requested drug is 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 Imfinzi have not been met. Specifically, the file shows that the requested drug is 
not approved by the FDA for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-
approve Imfinzi (J9173).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure. 
 
You asked the Plan to pre-approve Ensure. You say that you have a hernia in your esophagus and cannot 
swallow. You say that you are 91 years old and have been losing weight. You say that your doctor wants you to 
use Ensure. You say that your over the counter benefit is exhausted monthly on diapers and wipes. The Plan 
denied your request. The Plan says orally administered enteral nutrition products are non-covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac (SI) joint radiofrequency ablation (RFA) 
provided on September 2, 2021. 
 
You asked the Plan to pay for the SI RFA. You say that you would like reconsideration because this procedure 
was medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 pay for the SI RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.  Studies completed 
say that this procedure does not improve outcomes compared to standard treatment of SI joint pain. 
 
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 SI RFA have not been met. Therefore, we decided that the Plan does not 
have to pay for the sacroiliac (SI) joint radiofrequency ablation (RFA) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you were referred to an out-of-
network provider and the in-network provider does not have available dates. The Plan denied your request. The 
Plan says there is an approved referral to see an in-network provider. Also, a list of in-network providers was 
given to the enrollee that provide the same quality of service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panzyga (J1599). 
 
You asked the Plan to pre-approve panzyga. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs. 
 
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 panzyga. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed any of the plan's preferred step one alternatives. 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. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panzyga have not been met. Specifically, the file does not show that the enrollee 
has tried and failed any of the preferred drugs. Therefore, we decided that the Plan does not have to pre-
approve panzyga (J1599).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humalog injection. 
 
You asked the Plan to pre-approve Humalog. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Humalog injection.  
 Benefits for Humalog 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that it is your medical opinion that Xiidra should be 
covered for the enrollee, as she has failed on the preferred Restasis. The Plan denied your request. The Plan 
says Xiidra is a self-administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Xiidra.  
 
Benefits for Xiidra 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor (K0553). 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 Day Sensor. You say that you would benefit from 
wearing a CGM to avoid multiple finger sticks. The Plan denied your request. The Plan says you did not meet 
the criteria requirements for coverage. 
 
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 14 Day Sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 14 Day Sensor (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zenpep. 
 
You asked the Plan to pre-approve Zenpep. The Plan denied your request. The Plan says Zenpep is a self-
administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Zenpep.  
 
 
 
 
 
  
Benefits for Zenpep 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 pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you need the crown replaced. The Plan denied your 
request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 
5 Plan years. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Specifically, the record shows that you had exceeded the frequency 
limit for this service on January 8, 2020. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arterial puncture (36600), autologous blood collection 
processing and storage (86891), special pump services (99190 and 99191) and washed red blood cells (P9022) 
provided on August 11, 2021.  
You asked the Plan to pay for the arterial puncture, autologous blood collection processing and storage, special 
pump services and washed red blood cells. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says payment for these services is included in the payment 
to the facility and CPT code 36600 exceeds the MUE. 
 
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value for that HCPCS/CPT code will be denied. The rules also say that all items and non-physician 
services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. 
 
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 the arterial puncture. Our reviewer says that 
the provided documentation does not support that the additional unit of CPT code 36600 was 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 arterial puncture, autologous blood collection processing and storage, 
special pump services and washed red blood cells have not been met. Specifically, the documentation does not 
support that the additional unit of 36600 was medically necessary. Additionally, payment for the autologous 
blood collection processing and storage, special pump services and washed red blood cells is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the 
Plan does not have to pay for the arterial puncture (36600), autologous blood collection processing and storage 
(86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on August 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services received from July 28, 2021, to August 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 find that CPT code 97530 is not supported in the medical record. Specifically, there is a more appropriate 
code to use in this case for services in the home. 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 pay for 
therapy services received from July 28, 2021, to August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on October 13, 2021. 
 You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 
and 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal assistance services. 
 
You asked the Plan to pre-approve personal assistance services. You say that this care is necessary as a result 
of your accident. The Plan denied your request. The Plan says this is not covered according to Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal assistance services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal assistance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy (97161), therapeutic procedures 
(97110, 97112), manual therapy techniques (97140), therapeutic activities (97630), ultrasound (97035), and 
electrical stimulation (G0283), to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the exercise and other therapies. You say that the services should be 
covered. The Plan denied your request. The Plan says there are in-network providers available to the member 
for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy (97161), therapeutic procedures (97110, 97112), manual therapy techniques (97140), 
therapeutic activities (97630), ultrasound (97035), and electrical stimulation (G0283), to be provided by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone Bitartrate/Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone Bitartrate/Acetaminophen. The Plan denied your request. The 
Plan says Hydrocodone Bitartrate/Acetaminophen is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Hydrocodone 
Bitartrate/Acetaminophen.  
 
Benefits for Hydrocodone Bitartrate/Acetaminophen 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Gemtesa.  
 Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.