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

 
We decided that the Plan does not have to pre-approve Romosozumab-aqqg (Evenity). 
 
You asked the Plan to pre-approve Evenity. You say that you want to start the enrollee on a potent agent, as 
Romosozumab (Evenity) has strong evidence of improving bone mineral density and reducing the risk of 
fracture. The Plan denied your request. The Plan says medical necessity is not 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 Evenity. Our reviewer says that Evenity 
is not reasonable and necessary for the enrollee. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drugs, Reclast, Forteo, Prolia, or Tymlos. Our reviewer also found that 
there is no indication that the Plan's required drugs 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Romosozumab-aqqg (Evenity).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 17, 2022, billed 
with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says only one code should be submitted for a panel. 
 
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 February 17, 2022, 
billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81335 and 81355.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bioimpedance spectroscopy for lymphedema provided on 
December 1, 2021. 
 
You asked the Plan to pay for bioimpedance spectroscopy for lymphedema. You say that bioimpedance 
spectroscopy for lymphedema is medically necessary. The Plan denied your request. The Plan says 
bioimpedance spectroscopy for lymphedema is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for bioimpedance spectroscopy for 
lymphedema. Our reviewer says that bioimpedance spectroscopy for lymphedema is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case; the record indicates that the 
enrollee has a history of breast cancer. The record indicates that the enrollee does not have edema. The safety 
and efficacy of the requested service to be used in the enrollee's clinical condition has not been established. 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.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy for lymphedema have not been met. Therefore, we 
decided that the Plan does not have to pay for bioimpedance spectroscopy for lymphedema provided on 
December 1, 2021.
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 LTACH care is medically necessary. 
The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility. 
 
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 was admitted with abdominal pain and underwent operative intervention 
for advanced ovarian cancer. The record indicates that the enrollee still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.  
 
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: 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. The Plan denied your request. The Plan says the 
LTACH services you are requesting do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are 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 Plan. Our reviewer also 
found that 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that admission to the SNF is needed. The Plan 
denied your request. The Plan says the records do no show that the enrollee needs skilled nursing or skilled 
rehabilitation services on a daily basis in an inpatient setting. 
 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 the SNF admission. Our reviewer says 
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the provided 
documentation does not indicate that the enrollee requires skilled nursing services. The reviewer found that 
while the enrollee does require skilled therapy services, they are not required on a daily basis. The reviewer 
also found that there is no documentation that the enrollee requires the services on an inpatient basis, only in a 
skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts or fusion material, service to explore your 
fusion, and fuse the front of your spine. 
 
You asked the Plan to pre-approve bone grafts or fusion material, service to explore your fusion, and fuse the 
front of your spine. 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 bone grafts or fusion material, service 
to explore your fusion, and fuse the front of your spine. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. 
Additionally, there is limited published, large-scale, long-term peer-reviewed literature that shows the 
requested Globus Signify ceramic-based allograft to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested bone grafts or fusion material, 
service to explore your fusion, and fuse the front of our spine, in this case, is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone grafts or fusion material, service to explore your fusion, and fuse the front 
of your spine have not been met. Therefore, we decided that the Plan does not have to pre-approve bone grafts 
or fusion material, service to explore your fusion, and fuse the front of your spine.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's nursing, medical management and rehabilitation needs do 
not require an interdisciplinary team approach to delivery of rehabilitation care. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervico-thoracic 
surgery. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF 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 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 for the enrollee.
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 a skilled nursing facility does not have the resources 
for the enrollee to get better. The Plan denied your request. The Plan says the enrollee is unable to take part in 3 
hours of therapy a day. 
 
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 the enrollee was admitted to the acute hospital for rib and vertebral fractures after a fall and was discharged 
home with home health services. There is ongoing weakness. His medical problems are stable. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation in all four quadrants (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says that gingival irrigation (D4921) is not a covered dental 
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. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation in all four quadrants (D4921).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says no 
ongoing skilled needs have not been identified 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 Continued home health services beyond September 2, 2022, were requested. 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 home health services. Our physician reviewer found that you have a past 
medical history of a stroke, rhinitis, migraine and insomnia. The provided records do not document any acute 
or unstable medical conditions or changes in medication or treatment which would necessitate any further 
skilled nursing visits beyond what has already been approved. The records document that you have been 
educated on your disease process and medications. The records do not document the need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. There is no documentation that 
the requested home health services meet the Medicare criteria for medically reasonable and 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that further therapy could be addressed at a lower level of 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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There is no documentation that you require skilled 
nursing services. You do require skilled therapy services. There is no documentation that further daily skilled 
services are required. You are walking greater than household distances with a wheeled walker with stand-by 
assistance/supervision and are supervision to modified independent for transfers. Provided records do not 
document a significant decline in your functional status to necessitate further daily inpatient skilled therapy 
services. There is no documentation that you require the services on an inpatient basis, only in a skilled nursing 
facility setting. Our physician reviewer found that your condition does not meet Medicare criteria for continued 
SNF services. 
 
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 continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel allograft and Infuse BMP-2 bone 
graft cage device. 
 
You asked the Plan to pre-approve Nuvasive Osteocel allograft and Infuse BMP-2 bone graft cage device. 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 Nuvasive Osteocel allograft and Infuse 
BMP-2 bone graft cage device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found however, there is limited 
published, large-scale, long-term peer-reviewed literature that shows Nuvasive Osteocel allograft and Infuse 
BMP-2 bone graft cage device to be an effective and/or safe treatment for the noted pathology. Further studies 
are needed. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Nuvasive Osteocel allograft and 
Infuse BMP-2 bone graft cage device, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nuvasive Osteocel allograft and Infuse BMP-2 bone graft cage device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Nuvasive Osteocel allograft and 
Infuse BMP-2 bone graft cage device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your current needs can be met at an alternate level of 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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. You do not have documented skilled nursing needs. 
You do not have documented skilled therapy needs. You are ambulating household distances and tending to 
activities of daily living with minimal supervision. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your needs, custodial and intermittent, can, 
as a practical matter, be provided at a lower level of care. Our physician reviewer found that your condition 
does not meet Medicare criteria for continued SNF services. 
 
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 continued skilled nursing facility (SNF) services.