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

 
We decided that the Plan does not have to pre-approve Imlygic. 
 
You asked the Plan to pre-approve Imlygic. The Plan denied your request. The Plan says the drug is not 
supported for the enrollee's condition. 
 
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 Imlygic. Our physician reviewer found 
that Imlygic has been requested to treat recurrent squamous cell skin cancer of the legs. Imlygic is not FDA 
approved for squamous cell skin cancer. The drug is not supported for this use in any of the CMS approved 
compendia. The use is not listed as not indicated, not recommended or not supported in any of the compendia. 
The documentation support that the requested drug is safe and effective, and otherwise reasonable and 
necessary for this 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 Imlygic have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imlygic.
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 the enrollee needs these services to reach her prior 
level of functioning. The Plan denied your request. The Plan says that ongoing skilled services can be provided 
at a lower level of 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 above. 
 
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 
patient is medically stable after a hip fracture and surgery with no evidence of complex medical issues that 
require monitoring by an inpatient physical medicine and rehab physician three times per week or need for 
acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no 
evidence of need for an intensive therapy program with or therapy 3 hours per day with frequent physician 
oversight and an interdisciplinary approach to rehabilitation care. The enrollee's rehab needs can be met at an 
alternate, low intensity level setting. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with code L1833. 
 
You asked the Plan to pay for knee orthosis. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this item is correct, because the documentation submitted 
includes no objective examination to show any instability, ligamental laxity, or deformity. 
 
The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination 
of the beneficiary and objective description of joint laxity for coverage of knee orthosis L1833. 
 
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 knee orthosis.  
Our reviewer says that this knee orthosis does not meet the Medicare criteria for payment. Our physician 
reviewer found based on the records provided there is no evidence of any instability, ligamental laxity, or 
deformity of the knee joint. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis with code L1833.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan. You say that you are appealing. The Plan denied your request. The 
Plan says that the denial of authorization for this service is correct, because this CT scan is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for this CT scan. Our physician reviewer found the enrollee has an 
undiagnosed condition that would benefit from the results of this scan in differential diagnosis. Evaluating for 
lymphadenopathy with CT would help with the diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a Computed Tomography (CT) scan of the chest.  
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit provided June 3, 
2020. 
 
You asked the Plan to waive the copayment for the Emergency Room visit. You say that you thought you were 
going to urgent care so the copayment should be reduced to the urgent care amount of $60. The Plan denied 
your request. The Plan says the correct copayment was applied for the services rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the Emergency Room visit. The Emergency Room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
Emergency Room visit provided June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on March 10, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was a wellness exam. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for physician/practitioner services/in-network.  
 
You have been asked to pay a $15 copayment for an office visit. When services are provided that go beyond a 
wellness exam additional copayments are applied; therefore, the correct copayment has been applied. An office 
visit falls within the physician/practitioner services/in-network benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided by a participating provider on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids and services provided from February 6, 2020 to 
May 10, 2020. 
 
You asked the Plan to pay for these hearing aids and services. You say that your hearing aids were broken, and 
they needed to be replaced. The Plan denied your request. The Plan says the provider used is not a Plan 
approved provider and is considered out of network. The Plan says that enrollees must use network providers 
listed in the contract for hearing aids to be covered.  
 
Medicare does not pay for hearing aids or related services. The Plan offers a hearing aid benefit that exceeds 
Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays for hearing 
aids when they are purchased from a network provider. You did not purchase these hearing aids from a network 
provider. Therefore, we decided that the Plan does not have to pay for hearing aids and services provided from 
February 6, 2020 to May 10, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on April 15, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the genetic testing by a contract provider. The file does not show that the Plan provided 
notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic testing is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the genetic testing 
provided on April 15, 2020.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on March 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (adhesiolysis). 
 
You asked the Plan to pre-approve adhesiolysis. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because this procedure is still being studied 
to determine whether it is as good or better than the standard treatment for the enrollee's condition. 
 
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 adhesiolysis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational because it has never had a head-to-
head trial with conventional therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adhesiolysis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous lysis of epidural adhesions (adhesiolysis).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 3, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required 
(D2950 x3). 
 
You asked the Plan to pre-approve the core buildups. You say that you do not understand why the crown has 
been approved, but not the post. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 three 
core buildups, including any pins when required (D2950 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have foot pain. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on September 
15, 2019. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not eligible for Hospice. The 
Plan denied your request. The Plan says the enrollee was enrolled in Hospice and Original Medicare is 
responsible for payment of these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on September 
15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99349) provided on April 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that prior authorization is not needed for telemedicine. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home visit (99349) provided on April 15, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen set up for surgery for the enrollee provided on March 
11, 2020. 
 
You asked the plan to pay for this service. You say that this claim should be paid. The plan denied your 
request. The plan says this claim cannot be paid separately based on Medicare guidelines for this type of 
service.  
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility. Payment for this 
service would have been included under the facility claim. Payment to you for this service is the responsibility 
of the facility or hospital. Therefore, we decided that the Plan does not have to pay for oxygen set up for 
surgery for the enrollee provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on December 19, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from August 
21, 2019, through December 31, 2019. The Plan says, per Medicare guidelines, the provider needs to submit a 
bill to Original Medicare for the services rendered on December 19, 2019. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires this to transition 
from his acute illness. The Plan denied your request. The Plan says that the enrollee's complex medical needs 
are being met in the current acute setting at this time. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for sepsis and weakness. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH 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 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 for the enrollee.
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 enrollee is capable of rehab for 3 hours a day. 
The Plan denied your request. The Plan says the enrollee does not need to be seen by a rehab doctor at least 3 
times a week, or an intensive rehab team for 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 above. 
 
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 are independent with bed mobility, sitting up, and donning prosthesis. You are at a contact guard assist 
for standing up and walking. You do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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.