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

We decided that the Plan does not have to pre-approve Trastuzumab (Herceptin). 
 
You asked the Plan to pre-approve Herceptin. The Plan denied your request. The Plan says the drug is not 
being used as first-line therapy. 
 
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 Herceptin. Our physician reviewer 
found that the requested use of Herceptin is not FDA-approved for the enrollee's diagnosis. The drug is covered 
for the treatment of HER2-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma (in 
combination with cisplatin and either capecitabine or 5-fluorouracil) in those who have not received prior 
treatment for metastatic disease. This enrollee has had 2 prior lines of therapy. 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 
documentation does not 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 Herceptin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trastuzumab (Herceptin).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says neither 
diagnostic blocks provided 80% relief. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. He has undergone 3 sets of medial branch blocks. 
The pain relief achieved ranged from 40-70%. Coverage criteria requires dual diagnostic blocks that produce 
80% or greater pain relief which was not achieved here. The injections are considered negative. Therefore, the 
requested procedure is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued psychotherapy sessions with a Marriage 
Family Therapist. 
 
You asked the Plan to pre-approve continued psychotherapy sessions. You say that you want to remain with the 
requested provider for the duration of the Covid-19 situation. The Plan denied your request. The Plan says you 
were authorized in May 2020 for visits to help you transition to a new and appropriate provider so now you 
must reach out to the Plan for a referral to a new provider covered by your primary insurance. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continued psychotherapy sessions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued psychotherapy sessions with a Marriage Family Therapist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided the requested 
physician. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan requires you to receive care from providers who are part of your primary care physician's (PCP) 
specialty network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested physician.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional routine transportation trips. You say that you need more trips to your 
doctor's office. The Plan denied your request. The Plan says you have used all of your non-emergency medical 
transport benefit trips for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98942). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial as you have right shoulder pain. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of chiropractic care as the medical records provided do not demonstrate that you have a subluxation 
of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the record does not show that you have a subluxation 
of the spine demonstrated by x-ray or physical exam. Therefore, we decided that the Plan does not have to pre-
approve chiropractic manipulative treatment (98942).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power options for a power wheelchair 
(E2313, E2311, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records indicate his upper extremity strength and function are sufficient to control 
the power options using their own switches which are included in the allowance of these power options. 

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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power options for a power wheelchair (E2313, E2311, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested outpatient diagnostic services. 
 
You asked the Plan to pre-approve the outpatient diagnostic services. The Plan denied your request. The Plan 
says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested outpatient diagnostic services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Intracept system (22899, C1889, C9753, C9752). 
 
You asked the Plan to pre-approve a Intracept system. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 a Intracept system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure remains experimental. More research is needed to show 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Intracept system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Intracept system (22899, C1889, C9753, C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown (D2954).

You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown is not listed as a covered service. The Plan also says if a dental item or service is not listed in the benefit chart then it 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 a prefabricated post and core in addition to a crown (D2954).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical anterior decompression with fusion (ACDF). 
 
You asked the Plan to pre-approve a cervical ACDF. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 a cervical ACDF. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found criteria for surgery is not met. There is no documentation of adequate conservative 
measures to include recent physical 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 a cervical ACDF have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cervical anterior decompression with fusion (ACDF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation treatment. 
 
You asked the Plan to pre-approve radiation treatment. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 radiation treatment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found radioembolization is not considered medically necessary as treating a patient with 
radioembolization whose liver metastases are not refractory to standard treatment is not in accordance with 
accepted standards of 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 radiation treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional hearing aid (V5257). 
 
You asked the Plan to pre-approve an additional hearing aid. You say that the items are necessary. The Plan 
denied your request. The Plan says the covered benefit has been exhausted. 
 
Medicare does not pay for hearing aids or related services. However, 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 pays $1,500 
maximum for hearing aids every 2 years.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of an additional hearing aid have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an additional hearing aid (V5257).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466) to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a portable ventilator to be provided by an OON provider. You say that the 
item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide this item. Therefore, coverage criteria has not been met. 
 
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 
a portable ventilator (E0466) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right knee geniculate nerve block injection (64624). 
 
You asked the Plan to pre-approve a right knee geniculate nerve block injection. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has 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 a right knee geniculate nerve block 
injection. 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 
and therefore, the procedure is considered 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 a right knee geniculate nerve block injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a right knee geniculate nerve block injection (64624).
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 continued services. You say that you are not ready to go home. The Plan 
denied your request. The Plan says you do not require skilled nursing services, and have returned to your prior 
baseline level of function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
Continued services beyond November 6, 2020, was 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 continued services. Our physician reviewer found that the most recent therapy notes 
indicate you are able to ambulate up to 150 feet and accomplish most activities of daily living independently. 
You do not have any parental medications, complex wound care or nutrition given via a feeding tube.  You do 
not require any skilled nursing or rehab services on a daily basis. As a practical matter, you do not require any 
skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued 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: 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 SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 most recent therapy notes indicate the enrollee has declined in function. She has an unsteady gait 
with poor balance, but is able to use a manual wheelchair. She does not require any skilled nursing or rehab 
services on a daily basis at an inpatient level of care. She is not expected to make measurable gains within a 
reasonable and predictable period of time, or require skilled therapy to prevent deterioration with mobility or 
activities of daily living. The enrollee did not have any parental medication, complex wound care or nutrition 
given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems.  
Her physical function was at or near her baseline. Therefore, an admission to a SNF for inpatient skilled rehab 
services was 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 a skilled nursing facility (SNF) admission.