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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not safe to go home independently. 
The enrollee is not able to walk or administer insulin on her own. 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 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. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable 
expectation that the enrollee will be able 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have 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 
requirements for coverage of Injectafer have not been met. Our physician reviewer found he Plan requires a 
trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. The record 
does not show that the enrollee has tried these drugs, that these drugs would be less effective, or that these 
drugs would have adverse effects 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0140) provided on March 26, 2021. 
 
You asked the Plan to pay for the oral evaluation. You say that you would like reconsideration because you 
were not aware of the frequency limitation. The Plan denied your request. The Plan says you previously 
exhausted this benefit. 
 
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. Specifically, the record shows that the Plan previously issued payment 
for service D0140 date of service February 22, 2021. The limited oral evaluation rendered on March 26, 2021 
exceeds the frequency limitations as described in your contract with the Plan. Therefore, we decided that the 
Plan does not have to pay for the oral evaluation (D0140) provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493) and injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (CPT code 64494). 
 
You asked the Plan to pre-approve the services. You say that the enrollee was diagnosed with lumbar facet 
syndrome and medications such as non-steroidal anti-inflammatory drugs (NSAIDS) and muscle relaxants have 
failed to satisfactorily control the enrollee's pain without causing unwanted side effects. You state that the 
lumbar medial branch nerve blocks are necessary to directly address the nerve impingement and local irritation, 
and the procedure needs to be done in a timely fashion to prevent the enrollee's continued suffering from pain. 
The Plan denied your request. The Plan says the record does not document absence of untreated radiculopathy 
or neurogenic claudication despite the diagnosis of lumbar radiculopathy, and also does not document any prior 
physical therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found according to the coverage criteria: Facet Injections require the absence of untreated radiculopathy or 
neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst).  In this case, there is 
documentation of radiculopathy. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT 
code 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 you are medically stable and does not need physical medicine and rehabilitation 
(PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs identified or 
documented in the record. At the current functional level, you do not need IRF level of therapies, and your rehabilitation needs can be met in a skilled nursing facility (SNF). IRF admission is not medically necessary 
based on medical stability and lack of medical complexity, and lack of rehabilitation nursing needs. Document 
does not support the necessity for admission to an IRF. While you may benefit from physical therapy (PT), and 
occupational therapy (OT), your rehabilitation can be safely provided at a lower intensity and alternate setting 
such as in an SNF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on September 14, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
does not show the amount of time that was spent rendering the critical care services. Based on this information, 
we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services (99291) provided on September 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve membrane graft (CPT code Q4205). 
 
You asked the Plan to pre-approve the graft. You say that the graft is necessary. The Plan denied your request. 
The Plan says the membrane graft is not medically necessary for any indication due to insufficient evidence of 
efficacy. 
 
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 graft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the current medical literature on membrane graft therapy for wounds, there is no strong and 
convincing evidence of the safety, efficacy and necessity of the requested membrane graft treatment for your 
wound in this case as required by Social Security Act, Section 1862(a)1(A). 
 
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 graft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve membrane graft (CPT code Q4205).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of care (CPT code 99215) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are receiving long term care 
from this provider, and you would like to continue treatment with them. The Plan denied your request. The 
Plan says this provider is leaving the network and you have been redirected to an in-network oncologist to 
continue services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve the out-of-network services.  
 Our physician reviewer found the reviewed documentation indicates that you are noted to be on a stable 
treatment regimen for lung cancer, able to be transitioned to in-network provider to re-establish in network and 
to continue current treatment regimen. The review indicates that the out-of-network items/services at issue in 
this case are 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 the out-of-network services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve continuation of care (CPT code 99215) to be provided by an out-of-
network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of soft tissue localization devices (10035) 
provided on August 27, 2021. 
 You asked the Plan to pay for the placement of soft tissue localization devices. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this service 
exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 10035 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
placement of soft tissue localization devices have not been met. Therefore, we decided that the Plan does not 
have to pay for the placement of soft tissue localization devices (10035) provided on August 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eligard (CPT code J9217). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the use of Eligard for prostate cancer when orchiectomy and/or estrogen 
administration are indicated, and the patient is willing to attempt these therapies is not a medically accepted 
indication. 
 
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 the medication. Our physician reviewer 
found the use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The use is listed as not indicated, not supported or not recommended in any of 
the compendia. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eligard (CPT code J9217).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214). 
 
You asked the Plan to pre-approve an upper and lower partial denture. You say that you would like the 
dentures covered. The Plan denied your request. The Plan says these services are not covered under your 
benefits. 
 
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 
maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5214).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet 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 the enrollee is receiving appropriate care at the present acute care hospital. 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee is now blind due to not getting the 
correct treatment she needed. You also say that it is unacceptable for the plan to deny these services when the 
enrollee has already been seen by an in-network eye doctor and no one has been able to assist her instead her 
condition has worsened. The Plan denied your request. The Plan says the enrollee must use network providers 
to get medical care and services when there are network providers available. The in-network providers were 
contacted and can provide the requested 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 
an office visit with an ophthalmologist to be provided by an out-of-network (OON) provider.  
 
Your complaint about the enrollees condition being worsened is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab (Evenity). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee has had no other osteoporosis treatment. 
You also say that getting patients with severe osteoporosis on antibiotics first achieves better bone density 
improvement than using anabolics after an antiresorptive like Prolia or Reclast. The Plan denied your request. 
The Plan says the request for treatment of osteoporosis in a male member with Romosozumab (Evenity) is 
denied based on lack of medical necessity or evidence-based support for this treatment indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and 
Drug Administration (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 Evenity. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the enrollee has a diagnosis of age-related osteoporosis without current pathological 
fracture. Our reviewer found that the Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. Our physician reviewer also found that the Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Romosozumab (Evenity).