Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the SIJ injection. You say that it is felt that this would be beneficial. The 
Plan denied your request. The Plan says the previous SIJ injection did not produce significant relief. As such, a 
repeat treatment is not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SIJ injections may be covered when the criteria above 
are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SIJ injection. Our reviewer says that 
the requested service is not considered medically reasonable and necessary. Our physician reviewer found this 
is a 69-year-old enrollee with diagnoses of Sacroiliitis, not elsewhere Classified. The enrollee has a history of 
post-laminectomy syndrome and is status post spinal cord stimulator implant. The provided medical record 
dated 8/7/2020 states that the enrollee has had a previous SIJ injection on 8/19/2019 without any relief. Based 
upon the submitted medical records, coverage for the requested procedure 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 the SIJ injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine received on January 13, 2020. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine received on January 
13, 2020.  
 
Benefits for the Shingles vaccine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has poor performance 
status and multiple comorbidities with newly diagnosed Hodgkin's lymphoma. Keytruda is not FDA approved 
for first line treatment of Hodgkin's lymphoma. The drug is not supported in any of the Medicare-approved 
compendia for this use. The documentation does not support that the drug is safe and effective for the enrollee. 
Keytruda 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued inpatient services. The Plan denied your request. The Plan says 
you do not have acute symptoms that require 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
The documentation shows that continued care from October 19, forward, 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 inpatient services. Our physician reviewer 
found that active treatment was not taking place. The services were not reasonably expected to improve your 
condition or for the purpose of diagnosis. Based upon review the records, you were not shown to be a danger to 
yourself or others. You were not showing any auditory or visual hallucinations, and were 
cooperative/compliant with treatment while not showing any threats the safety. 
 
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 inpatient services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on April 30, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you do not understand how the claims were reprocessed multiple times. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $40 copayment for specialist services. 
 
You had a Medicare Part B drug injection on April 30, 2020. Therefore, you are responsible to pay $582.44, 
which is less than the 20% coinsurance amount.  
 
You received the administration of a Medicare Part B drug on April 30, 2020. Therefore, you are responsible to 
pay $23.32 which is less than the total copayment amount. The total amount you owe is: $605.76.  
 
You have been asked to pay the total amount of $605.76 a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the physician/practitioner services, including doctor's office visits 
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 coinsurance for a Medicare Part B drug 
injection and does not have to waive the copayment for the administration provided on April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Retacrit provided to the enrollee on Marcy 24, 2020. 
 
You asked the Plan to pay for this treatment. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim submitted does not contain an appropriate diagnosis code for Retacrit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted does not contain a 
covered diagnosis code or indication for Retacrit. Based on this information, we decided that Medicare rules 
for coverage of this treatment have not been met. Therefore, we decided that the Plan does not have to pay for 
Retacrit provided to the enrollee on Marcy 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches. 
 
You asked the Plan to pre-approve Fentanyl. You say that the drug is part of the enrollee's daily regimen. The 
Plan denied your request. The Plan says the drug is not covered for the enrollee's condition under Medicare Part 
B. 
 
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 Fentanyl patches.  
 
Benefits for Fentanyl 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 
13, 2018, to November 20, 2018. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this surgery and stay 
were due to complications of a previous surgery. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $360 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from November 13, 2018, to November 20, 2018. Therefore, you are 
responsible to pay a $360 copayment for days 1-5 (November 13, 2018, to November 17, 2018). $360 
(copayment) x 5 (inpatient days) = $1,800. 
 
You have been asked to pay the total copayment amount of $1,800 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from November 13, 2018, to November 20, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a pain pump for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that Medicare rule says that a pain pump is not covered when a 
member has other implanted programmable devices. 
 
The Plan must follow Medicare rules. Medicare rules say that implantation of infusion pump is contraindicated 
with other implanted programmable devices.  
 
We looked at the file and Medicare rules. The file indicates that the enrollee already has an implanted spinal 
cord stimulator. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a pain 
pump for the enrollee.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that continued management can be provided in the acute care 
hospital until the enrollee's course of care is complete. 
 
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 
appears to be worsening and requires additional short-term acute care services to help stabilize before 
considering transfer to a different location. The patient does not require services at the LTACH that are not 
already provided and available at the current facility. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation function (E2300) for a power 
chair. 
 
You asked the Plan to pre-approve the power seat elevation function. You say that the feature is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the power seat elevation function is not covered.  
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the power seat elevation function have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation function (E2300) for a power chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets rehabilitation admission 
criteria under CMS guidelines. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services do not meet the requirements for approval. 
 
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. Our 
physician reviewer found that based on the documentation provided, the health plan's denial should be 
upheld.  The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollee's care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9501 provided 
from March 23, 2020, to March 26, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 CPT Code Manual definition of code S9501 is home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9501 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9501 provided from March 23, 2020, to March 
26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of vitreous 
hemorrhage in the right eye. Vitreous hemorrhage is not an indication for Eylea. The services are therefore not 
safe and effective or reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic BRCA testing. 
 
You asked the Plan to pre-approve the genetic BRCA testing. You say that  The Plan denied your request. The 
Plan says Medicare rules for coverage of the requested testing have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA testing is covered for 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 genetic BRCA testing. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is not noted to 
have a personal history of breast cancer, ovarian cancer, fallopian tube cancer, peritoneal cancer or pancreatic 
cancer. The requested testing appears to be for screening purposes. Therefore, the documentation does not 
support that the requested testing is medically necessary or reasonable. 
 
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 genetic BRCA testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genetic BRCA testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you strongly believe that the Intracept 
procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied 
your request. The Plan says this procedure is not covered because it is considered experimental, investigational 
and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure.
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 enrollee can safely receive the services needed in other settings. 
 
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 
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 rib and back pain 
after a fall. The enrollee's 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 does document a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9502) provided from February 20, 2020, to 
February 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes. 
 
We looked at the file and Medicare rules. Code S9502 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 pay for the 
services (S9502) provided from February 20, 2020, to February 26, 2020.