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

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail one intravenous bisphosphonate therapy first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has 
age related osteoporosis without osteoporotic fracture. The requested medication is a new start. 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. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #11 and 27 (D6010), bone 
grafts on tooth #27 (D6104), bone replacement grafts on tooth #6, 8, 22, and 23 (D7953), and an unspecified 
implant procedure on tooth #5, 11, 21, and 27 (D6199). 
 
You asked the Plan to pre-approve two extractions, two bone grafts, the bone replacement grafts, and the 
unspecified implant procedures. You say that the requested dental services are medically necessary. The Plan 
denied your request. The Plan says bone replacement grafts (D7953) and unspecified implant procedures 
(D6199) are not covered by the enrollee's dental benefits. The Plan also says that the benefit for endosteal 
implants (D6010) and bone grafts (D6104) has already been exhausted. 
 
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, bone replacement grafts and 
unspecified implant procedures are not among those covered under this benefit. The record shows the 
enrollees benefit for endosteal implants and bone grafts were exhausted on the appeal request. Therefore, we 
decided that the Plan does not have to pre-approve endosteal implants on tooth #11 and 27 (D6010), bone 
grafts on tooth #27 (D6104), bone replacement grafts on tooth #6, 8, 22, and 23 (D7953), and an unspecified 
implant procedure on tooth #5, 11, 21, and 27 (D6199).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to take care of himself. 
The Plan denied your request. The Plan says the enrollee's needs are not skilled in nature. 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to the acute hospital with weakness and recurrent falls. The most recent 
therapy documentation indicates the enrollee is able to ambulate up to 400 feet without hands on assistance. 
The enrollee is medically stable and does not have any complex daily wound care, parental medications or 
required care for a new or malfunctioning feeding tube. The enrollee does not require skilled nursing or skilled 
therapy services on a daily basis. His physical function is at or near his baseline. Therefore, an admission to a 
SNF for inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee joint and shock reducing pylon feature for a 
prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic additions are covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found that the enrollee is documented to be a K3 
ambulator by the physical therapist, physician, and prosthetist. He has nearly full motor strength in his lower 
extremities as well as functional range of motion. He has had surgeries on his contralateral lower extremity, 
including a knee arthroplasty and foot surgery. He routinely negotiates uneven terrain and stairs. He would 
benefit from the microprocessor knee in terms of functional mobility and fall prevention as well as the shock 
reducing pylon feature given the volume changes in his residual limb and activity level. Therefore, the 
requested microprocessor knee joint and shock reducing pylon feature are 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a microprocessor knee joint and shock reducing pylon feature for a prosthesis.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that the requested Pembrolizumab is medically 
necessary. The Plan denied your request. The Plan says the requested Pembrolizumab 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 Pembrolizumab. Our reviewer says that 
the requested Pembrolizumab is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of adenocarcinoma of the distal third of the esophagus. The records provided are insufficient to establish the tumor characteristics required to determine if coverage is available under 
Medicare rules. The Food and Drug Administration 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. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
13, 2022, to November 6, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are requesting reconsideration for payment of SNF 
care. The Plan denied your request. The Plan says the enrollee no longer had skilled nursing facility needs. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee had no daily skilled nursing needs. The enrollee was stable on 
routine oral medications and insulin without symptoms. 
 
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 pay for skilled nursing facility (SNF) care provided from October 13, 2022, to November 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36592 billed for date of service October 24, 
2022.  

You asked the Plan to pay for procedure code 36592. You say that no authorization is required for these 
services, so these claims should be paid. The Plan denied your request. The Plan says payment for code 36592 
is bundled into payment for code 96374. 
 
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 36592 
is a column II code to column I code 96374 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 36592 billed for date of service October 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the case file does not 
contain documentation of trial and failure of one oral bisphosphonate and one intravenous bisphosphonate. The 
documentation does not support that one oral bisphosphonate and one intravenous bisphosphonate would likely 
be less effective, and/or would likely 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric connection device (E2311) and elevating 
power leg rests (E1012). 
 
You asked the Plan to pre-approve an electrical connection device and power leg rest. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that the coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are medically necessary when it 
is necessary to control the power options through the joystick. 
 
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 an electrical connection device and power leg rest. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found 
that the enrollee has adequate upper body strength to manage standard power drive switches. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection device and power leg rest have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electric connection device (E2311) and 
elevating power leg rests (E1012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 6, 2022, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting reconsideration and 
payment in full for the molecular PCR test performed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 6, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 
87798.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the member's needs can be met in a SNF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is functioning at a common post-acute level with minimal assistance. 
The enrollee does not have complicated or complex rehabilitation needs. This level of impairment is routinely 
managed without admission to an IRF and does not require a level of therapy available in the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature to support the safety and efficacy, as defined 
by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84165 and 84166 billed for date of service 
February 6, 2022. 
 
You asked the Plan to pay for procedure codes 84165 and 84166. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the services at issue were billed with an incorrect 
place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 84165 and 84166 are not supported. Specifically, the case record shows that the 
services at issue were billed as outpatient. All other services provided on the date of service at issue were billed as part of an inpatient stay. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 84165 and 84166 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 84165 and 84166 billed for date of service February 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 99291 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 procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0836) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee is 
functionally non-ambulatory and cannot use a cane or walker for mobility. However, there is limited clinical 
documentation provided as to why the enrollee cannot use a manual wheelchair for mobility when the primary 
issue with mobility is knee pain and osteoarthritis with a revision of her knee arthroplasty being required. The 
enrollee is noted to have 3/5 motor strength in the upper extremities and noted to be unable to perform pressure 
relief in the mobility evaluation. However, there is limited physical examination findings provided in the 
physician documentation and the clinical history to indicate that the enrollee has significant upper extremity 
pathology that would interfere with her ability to propel a manual wheelchair and preform pressure relief. The 
enrollee has no history of skin breakdown. Additionally, there is no history of lower extremity lymphedema 
requiring power elevating leg rests. As the power wheelchair base is not medically necessary, the requested 
accessories are not 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0836) and accessories.