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

 
We decided that the Plan does not have to pre-approve prostate artery embolization and related services. 
 
You asked the Plan to pre-approve prostate artery embolization and related services. You say that the requested 
prostate artery embolization and related services are medically necessary. The Plan denied your request. The 
Plan says the requested prostate artery embolization and related services are 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 prostate artery embolization and related 
services. Our reviewer says that the requested prostate artery embolization and related services are not 
medically necessary. Our physician reviewer found the enrollee is with BPH with LUTS that is refractory to 
medical therapy. He failed Rezum treatment 2 years prior. IPSS score is now 33 and prostate size is 130 cc 
with median lobe. 
 
Prostate artery embolization and related services are not medically reasonable and necessary for the enrollee in 
this case. Prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH. Very 
limited international studies have demonstrated possible short-term safety and efficacy. Comparative studies to 
other methods such as TURP are currently enrolling patients. The most recent AUA guidelines do not 
recommend this procedure outside of a clinical trial 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 prostate artery embolization and related services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve prostate artery embolization and related services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levobunolol 0.5% Eye Drops. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. The Plan must follow Medicare rules. The rules 
say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs 
requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the 
Plan does not have to pre-approve Levobunolol 0.5% Eye Drops. Benefits for the medication may be available 
under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning 
any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 4, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on May 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 he is 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 health plan. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient post-stabilization care provided June 18, 2020, 
June 25, 2020. 
 
You asked the Plan to pay for the inpatient post-stabilization care. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the services provided were unauthorized 
inpatient post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the inpatient post-stabilization care. Our 
reviewer says that the services were not reasonable or medically necessary. Our physician reviewer found it 
does appear the patient was stable at the time noted by the Plan and transfer should have been initiated at that 
point. 
 
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 inpatient post-stabilization care have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient post-stabilization care provided June 18, 2020, June 25, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Yervoy. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Yervoy which is used in combination 
with Opdivo for the treatment of hepatocellular carcinoma in enrollees that have been previously treated with 
sorafenib. It is not indicated for first line therapy. This enrollee has not received prior first line systemic 
therapy. The service is not reasonable or 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 Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on July 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 that you provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) tertiary level provider.
You asked the Plan to pre-approve the continuation of care with the OON provider. You say that you do not want to be seen by a new oncologist, as you do not want to disrupt the care you have been being provided. The Plan denied your request. The Plan says the enrollee's care can be transitioned to an in-network hematologist/oncologist, as the enrollee is currently stable.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continuation of care with the OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee is undergoing routine surveillance of his labs, with no treatment. The enrollee is able to get into see an in-network hematologist in a timely fashion. The Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through a referral to the in-network non-tertiary level provider. The enrollee is being followed for anemia of chronic disease and mild thrombocytosis. There is nothing unique about the enrollee's condition that would make it medically necessary to see the requested OON provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. 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 continuation of care with the OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) tertiary level provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 medical services provided on June 26, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on October 31, 2019. 
 
You asked the Plan to pay for the surgical pathology 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 
surgical pathology services. 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 surgical pathology services provided on October 
31, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept system (CPT Code(s): C9752, 22899). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the service(s) or procedure(s) is helpful for treatment 
of your health problem. 
 
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 services. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intracept system (CPT Code(s): C9752, 22899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a contracted tertiary level of care 
Neurosurgeon/Orthosurgeon. 
 
You asked the Plan to pre-approve an office visit with a contracted tertiary level of care specialist. You say that 
an office visit with a contracted tertiary level of care Neurosurgeon/Orthosurgeon is medically necessary. The 
Plan denied your request. The Plan says an office visit with a contracted tertiary level of care 
Neurosurgeon/Orthosurgeon is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 office visit with a contracted tertiary 
level of care specialist. Our reviewer says that an office visit with a contracted tertiary level of care 
Neurosurgeon/Orthosurgeon is not medically necessary. Our physician reviewer found the enrollee has been 
advised to continue conservative measures. There is no compelling reason for tertiary referral at this time. 
  
Surgery is not needed at this time. The request is not medically necessary for tertiary level 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 an office visit with a contracted tertiary level of care specialist have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an office visit with a contracted tertiary 
level of care Neurosurgeon/Orthosurgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) and the unspecified 
preventive service (D1999) provided on July 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not impressed with your entire dental 
appointment. You say that you thought you had an infection and the dentist did not even address it. You say 
that this was your very first claim so you do not understand how the frequency limit can be exceeded. You also 
say that you feel that you do not owe any money for the services you received that day. The Plan denied your 
request. The Plan says 1 periapical x-ray per year is covered. The Plan says that the frequency limit for this 
service has been exceeded. The Plan also says that the unspecified preventive service is not listed as a covered 
service. 
 
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 frequency limit of 1 periapical x-
ray per calendar year has been exceeded. The record shows that the Plan paid for 1 periapical x-ray that you 
received on the date of service.  Additionally, the unspecified preventive service is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray 
(D0230) and the unspecified preventive service (D1999) provided on July 16, 2020.  
 
Your complaint about your experience at the dental office is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided from February 21, 2019, to 
March 21, 2019. 
 
You asked the Plan to pay for oxygen equipment. You say that when you realized that this oxygen equipment 
was covered you submitted a claim, and these charges are a financial burden to you. The Plan denied your 
request. The Plan says the denial of payment for these items is correct, because the claim for payment was not 
submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for oxygen equipment was not filed until August 21, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for oxygen equipment provided from February 21, 2019, to March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 6, 2020 
and billed under code Q4121 JC (39 units). 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code Q4121 JC (39 
units) remains not supported. The documentation submitted indicates that Thera Skin was used as graft; 
however, documentation do not mention the size of the Thera Skin used; therefore, the billed service and units 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the records provided do not support 
the services billed. The records provided are incomplete concerning the number of units and size of Thera Skin 
used. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does 
not have to pay for physician services provided to the enrollee on July 6, 2020, and billed under code Q4121 JC 
(39 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection. 
 
You asked the Plan to pre-approve an epidural injection. You say that the requested epidural injection is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested epidural injection. 
 
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 an epidural injection. Our reviewer says 
that the enrollee does not meet criteria for the requested epidural injection. Our physician reviewer found the 
enrollee is with a history of chronic pain syndrome, osteoarthritis of the knees, low back and cervical neck 
pain, degenerative disc disease, displaced discs and radiculopathy. This request is for Lumbar/Sacral 
transforaminal epidural steroid injections. Medical records were provided. The provided records did not 
document failure of at least 4 weeks of non-invasive care. Therefore, this request is not 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 an epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural injection.