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

 
We decided that the Plan does not have to pre-approve Dalvance. 
 
You asked the Plan to pre-approve Dalvance. You say that the requested drug is medically necessary. You say 
that the drug being requested does not require a picc line. The Plan denied your request. The Plan says the 
records do not show that it is medically necessary for the enrollee to use the requested drug instead of the Plan 
preferred drug. 
 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 Dalvance. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug IV 
Vancomycin before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plans required drug would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dalvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Dalvance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
September 28, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the medical records and 
waiver should be reviewed to process the claim for payment. The Plan denied your request. The Plan says 
bundled services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the special anesthesia service (99100) have 
not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service 
(99100) provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis (J2778). 
 
You asked the Plan to pre-approve Lucentis. 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, bevacizumab. 
 
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 Lucentis. 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, bevacizumab. 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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis (J2778).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that you do not use insulin but are not able to 
prick your finger to do blood testing due to pain. This more advanced system would be best for you to help 
control your blood sugar. The Plan denied your request. The Plan says you do not meet criteria for this CGM. 
 
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. You stated in your appeal request that you have never used insulin. Based on 
this information, we decided that Medicare rules for coverage of the requested CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose 
monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 24, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on September 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to be admitted due to being unstable 
following knee and joint replacement. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested SNF services do not meet the requirements for approval. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs would be best met 
by transferring to the LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer Device. 
 
You asked the Plan to pre-approve the Vertiflex Interspinous Spacer Device. You say that you would like 
reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this 
procedure is unproven. 
 
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 Vertiflex Interspinous Spacer 
Device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex 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 Vertiflex Interspinous Spacer Device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer Device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orgovyx (relugolix) 120mg tablets. 
 
You asked the Plan to pre-approve the Orgovyx tablets. You say that this medication is necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says this is an oral drug that cannot be covered by 
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 Orgovyx (relugolix) 120mg 
tablets.  
 Benefits for the Orgovyx tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. Daily skilled services are not 
required. You are walking household distances with a 2-wheeled walker with stand-by assistance and are 
contact guard assist for transfers. Provided records do not document a significant decline in your functional 
status to necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term 
care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that you would like reconsideration 
because the requested service is medically necessary. The Plan denied your request. The Plan says this is an 
unproven procedure and 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 the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental in spine surgery when used as bone graft 
material. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has 
been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated 
inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. She 
could benefit from continued services at the current level of care. The enrollee has made slow progress with 
therapy, there is no indication that transfer to a skilled nursing facility is required. There are no services offered 
at a SNF that are not offered at an inpatient rehab facility. She can continue to receive skilled rehab services at 
the current IRF or be stepped down to a lower level of care when 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 you do not need to be 
seen by a rehabilitation doctor at least 3 times a week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 recurrent falls. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Outpatient Minuteman L4-5 Posterior Arthrodesis 
with Implantation of Hardware. 
 
You asked the Plan to pre-approve the Outpatient Minuteman L4-5 Posterior Arthrodesis with Implantation of 
Hardware. You say that you would like reconsideration because this procedure is medically necessary. The 
Plan denied your request. The Plan says you do 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 Outpatient Minuteman L4-5 
Posterior Arthrodesis with Implantation of Hardware. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation of lumbar instability, fracture or tumor. 
 
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 Minuteman L4-5 Posterior Arthrodesis with Implantation of 
Hardware have not been met. Therefore, we decided that the Plan does not have to pre-approve the Outpatient 
Minuteman L4-5 Posterior Arthrodesis with Implantation of Hardware.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (PWC). 
 
You asked the Plan to pre-approve the replacement PWC. You say that you received this PWC in March 2021 
which was broken when you received it. You state that you do not wish to have it examined to see if it can be 
fixed because they may not be able to fix it in the home and cannot give you a loaner. You feel that the only 
option is for a new PWC to be provided. The Plan denied your request. The Plan says a new PWC cannot be 
provided during the reasonable useful life of your current PWC, without an evaluation to show that it is 
damaged beyond repair. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for repairs to equipment 
up to the cost of replacement. Replacement may only be covered during the 5-year useful life when there is a 
specific incident which damages the item beyond repair. Replacement from wear from day-to-day activities is not covered within the 5-year lifetime. 
 
In this case, the current PWC has not been examined or evaluated to support that it is broken. Replacement 
could not be provided without objective evidence that the PWC is damaged or not working. Since the PWC is 
just one year old, replacement could only be approved in the case of manufacturer defect or a specific incident 
of damage. The PWC supplier must be given an opportunity to evaluate the chair to determine what can be 
done to fix the issues. Based on the lack of any actual documentation of damage, replacement cannot be 
considered necessary at this time. Therefore, we decided that the Plan does not have to pre-approve a 
replacement power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), a full 
mouth dental implant. 
 
You asked the Plan to pre-approve a full mouth dental implant. You say that you have been in this process for 2 
months already. You also say you have had most of your teeth extracted, and you need an implant at this time. 
You only have your two canine teeth, and it makes it difficult for you to chew food or eat. The Plan denied 
your request. The Plan says the requested services are not covered under your benefit plan. The Plan also says 
that you refused the two implants you are allowed per year, but you request the whole mouth of implants minus 
the two teeth you already have. 
 
  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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of an implant body (D6010), a full mouth dental implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synclara cough-stimulating device (E0482). 
 
You asked the Plan to pre-approve a Synclara cough-stimulating device. You say that this is necessary due to 
the enrollee's chronic cough and recurrent aspiration pneumonia. The Plan denied your request. The Plan says 
this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that mechanical in-exsufflation devices (E0482) are 
covered for beneficiaries who have a neuromuscular disease that causes a significant impairment of chest wall 
and/or diaphragmatic movement, such that it results in an inability to clear retained secretions.  
 
We looked at the file and Medicare rules. The submitted records do not show that the enrollee has a 
neuromuscular disease that causes a significant impairment of chest wall or diaphragmatic movement. Based 
on this information, we decided that Medicare rules for coverage of a Synclara cough-stimulating device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Synclara cough-stimulating 
device (E0482).