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

 
We decided that the Plan does not have to pre-approve Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. 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 drug, Zarxio. 
 
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 Udenyca. 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 the plan's preferred step one alternative. 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and sphere, single vision, plano to plus 
or minus 4.00, per lens (V2100) provided October 21, 2021, by an out-of-network (OON) provider.  
You asked the Plan to pay for the routine eyewear. You say that you have never had a problem using this 
provider before. The Plan denied your request. The Plan says this service is not covered because it was 
provided OON. 
 
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 these services when provided in-network. 
 
We looked at the file and the Plan's rules. In this case the eyewear was provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, 
we decided that the Plan does not have to pay for the frames (V2020) and sphere, single vision, plano to plus or 
minus 4.00, per lens (V2100) provided October 21, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy 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 no imaging evidence of a rotator cuff injury. 
 
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 detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there are no imaging studies provided to 
corroborate pathology in the right shoulder. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
 
 
 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 shoulder arthroscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), power 
seat elevator (E2300) and privacy bag (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller, power seat elevator, and privacy bag. You say 
that these features are medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met.  
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Items not primarily medical in nature are non-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 expandable controller, power seat 
elevator, and privacy bag. Our reviewer says that the requested items are not medically necessary. Our 
physician reviewer found the record shows that the enrollee has use of their hands and therefore can control the 
power features with the standard switches. The expandable controller is not medically necessary. The privacy 
bag and seat elevator are not primarily medical in nature and are non-covered. 
 
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 expandable controller, power seat elevator, and privacy bag have been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, 
E2313), power seat elevator (E2300) and privacy bag (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental care visits to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the dental care visits. The Plan denied your request. The Plan says you must 
use network providers to get medical care and services when there are network providers available. The Plan 
also says that no medical need is shown as to why you cannot be seen by a participating provider. 
 
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, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental 
care visits to be rendered by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that the enrollee cannot return to 
assisted living and has nowhere else to go. You say that the enrollee needs the catheterization to keep her from 
ongoing urinary tract infections and to prevent a decline in her health. The Plan denied your request. The Plan 
says the enrollee's medical issues have stabilized, and she does not meet the guidelines for coverage of 
continued SNF care.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 a continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 a continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) for teeth 2,3,4,5,28,29, and 30. 
 
You asked the Plan to pre-approve the endosteal implants. You say that you need dental implants because you 
cannot eat well. The Plan denied your request. The Plan says the implant is denied because the records show 
you are missing more than one tooth in this arch of your mouth. 
 
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 covers the endosteal 
implants when the implant will replace one missing tooth in an arch. 
 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 endosteal implants. Our reviewer 
says that surgical placement of implant body: endosteal implants (D6010) for teeth 2,3,4,5,28,29, and 30 do not 
meet criteria for coverage. Our physician reviewer found that a review of the documentation indicates that 
multiple implants are to be placed which is beyond the scope of the plan. Coverage for implants for multiple 
teeth are excluded. Coverage is only considered when a single tooth in an arch is to be replaced and if 
medically necessary. In this case other restorative treatments are possible. 
 
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 endosteal implants have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical placement of implant body: endosteal implant (D6010) for teeth 
2,3,4,5,28,29, and 30.
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 based on LTACH criteria. 
 
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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The does not enrollee 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the InSpan interspinous 
spacer/decompression device. 
 
You asked the Plan to pre-approve the InSpan procedure. You say that this is a medically necessary treatment. 
The Plan denied your request. The Plan says current evidence does not support this device as reasonable and 
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 the InSpan procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Inspan spacer is experimental. More research is needed. 
 
 
 
 
 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 InSpan procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the InSpan interspinous spacer/decompression device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram rendered on December 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable. 
 
The provider submitted a claim for procedure codes 77065 (diagnostic mammography, including computer-
aided detection, unilateral) and 77066 (diagnostic mammography, including computer-aided detection, 
bilateral). Code 77065 is a column II code with a modifier indicator of 0 when billed with column I code 
77066. Code 77065 is not separately payable. Therefore, we decided that the Plan does not have to pay for the 
mammogram rendered on December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the records provided support the 
need for an inpatient hospital admission. The Plan denied your request. The Plan says the enrollee does not 
meet the guidelines for coverage of an inpatient admission. The Plan says that if the enrollee develops medical 
issues after the surgery, a new request can be reviewed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. 
 Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided documentation suggested she passed preoperative clearance 
and didn't reveal any unstable issues that might require inpatient care. There was no suggestion from the notes 
that the enrollee would require hospital services that would likely cross 2 midnights for this typically 
ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from October 23, 2020, to October 30, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that the billed diagnosis code is 
supported. The Plan denied your request. The Plan says the billing of the secondary diagnosis code for Non-
Hodgkin lymphoma, unspecified, unspecified site (C85.90) is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code C85.90, defined as Non-
Hodgkin lymphoma, unspecified, unspecified site. 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 an additional amount for the inpatient care. Our reviewer says that the provided documentation does not 
support the billing of the secondary diagnosis code, C85.90. Our physician reviewer found the provided 
documentation indicates a personal history of Non-Hodgkin lymphoma was listed as a secondary diagnosis. 
The reviewer found; however, this condition did not directly influence care at the hospital and was unrelated to 
the course. Therefore, the reviewer found there was insufficient support made in the documentation for the 
secondary diagnosis of a personal history of Non-Hodgkin lymphoma.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for the inpatient hospital care provided from October 23, 2020, to October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a right wrist hand orthosis (L3916-RT) provided on 
December 20, 2021. 
 
You asked the Plan to pay for a right wrist hand orthosis. You say that this is supported in the records. The Plan 
denied your request. The Plan says the enrollee already had this item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that R. Gamble had previously received a right wrist hand orthosis in February 2021. The item 
at issue serves the same purpose as that wrist hand orthosis. Therefore, we decided that the Plan does not have 
to pay for a right wrist hand orthosis (L3916-RT) provided on December 20, 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. The Plan denied your request. The Plan says your ongoing needs 
can be provided at a lower level of care on an intermittent basis. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical 
problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy 
program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis (88360) provided on August 26, 
2021. 
 
You asked the Plan to pay for morphometric analysis. You say that this is separately payable. The Plan denied 
your request. The Plan says payment of this code requires a modifier.  
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 88360 
is a column II code to column I code 88321. 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 morphometric analysis (88360) provided on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic hysterectomy. 
 
You asked the Plan to pre-approve the requested hysterectomy. You say that you feel that it is clearly necessary 
to have this surgery due to the enrollee's infrequent menstrual periods. The Plan denied your request. The Plan 
says this is not a medically necessary surgery at this time. 
 
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 requested hysterectomy. Our 
reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 29-year-old woman who has previously undergone a 
laparoscopic tubal ligation. An intrauterine device (IUD) was removed in April 2021. The enrollee was on 
Depo-Provera for contraception and had a pulmonary embolism. On 2/10/22, it is documented that the enrollee 
takes Provera orally occasionally to get a menses. It is documented that the enrollee's menses are light, occur 
monthly, and last 4-5 days. The enrollee "has some cognitive delay and just does not want to take the Provera 
for her cycle control anymore."  
The documentation does not support that the enrollee has an accepted medically reasonable and necessary 
indication for hysterectomy, such as uterine leiomyoma, abnormal uterine bleeding, pelvic organ prolapse, 
pelvic pain or infection, or malignant/premalignant 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 the requested hysterectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a laparoscopic hysterectomy.