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

We decided that the Plan does not have to pre-approve an Ilaris (canakinumab) injection. 
 
You asked the Plan to pre-approve Ilaris. You say that you have been seen by 2 orthopedic doctors. You say 
that the only treatment that was offered is surgery. You also say that you are concerned about rehabilitation 
even if the surgery is successful. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Ilaris. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the requested drug is considered to be 
experimental. The reviewer found that the requested drug is not FDA approved for orthopedic use as intended. 
Therefore, the reviewer found that the requested drug is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilaris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an Ilaris (canakinumab) injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires enhanced 
supportive nutritional therapy. The Plan denied your request. The Plan says the enrollee does not have a 
permanent problem with his digestive tract. 
 
The Plan must follow Medicare rules. The rules say that records should document that the beneficiary cannot 
be maintained on oral or enteral feedings, and that due to severe pathology of the alimentary tract, the 
beneficiary must be intravenously infused with nutrients. 
 
We looked at the file and the rules. The records provided do not indicate that the enrollee suffers from a 
permanently impaired gastrointestinal tract, and that there is insufficient absorption of nutrients to maintain 
adequate strength and weight. Therefore, we decided that the Plan does not have to pre-approve intradialytic 
parenteral nutrition (IDPN).
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 services. You say that the enrollee is unable to take care of 
himself due to psychosis behaviors. The Plan denied your request. The Plan says the enrollee's condition has 
improved and he is no longer a threat to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from November 9, 2020, forward, were requested. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve continued services. Our physician reviewer found that active treatment was 
not taking place. The services were not reasonably expected or medically necessary to improve the enrollee's 
condition, or for the purpose of diagnosis. He was treated under an individualized treatment plan found in the 
record. Based upon review the records provided, this enrollee could be treated in a lesser restrictive setting as 
he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. He was 
not showing any behaviors or aggression. He was being cooperative and compliant while not showing any 
acute threats to 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care provided from November 14, 2020, forward. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found as of November 14, 2020, you did not require 
any skilled nursing or rehab services on a daily basis. You were 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 (ADLs). You did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a 
SNF level of care as of November 14, 2020. You did not have any parental medications, complex wound care 
or nutrition given via a feeding tube. You received skilled care and improved, however your function had 
plateaued by November 14, 2020, and did not require any further inpatient skilled rehab services. Your 
 
 
function was at or near your prior level of function and you could be discharged to a lower level of care for 
further services. During the point-of-care (POC) under review, you required custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care provided from November 14, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 6, 2020.
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 you would benefit from rehabilitation rather than a 
nursing home setting. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the way the 
claims were processed. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no four week trial of E0560 and E0561. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. 
 
Our physician reviewer found there is no evidence of lymphedema of the chest, trunk, or abdomen. The 
enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump. 
There is no documentation of a four week trial and failure of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit rendered on July 9, 2019. 
 
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 procedure code 99348 is not supported. 
 
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 99348 is Level 2 home visit for the evaluation and 
management of established patient with problem of low to moderate severity, including expanded problem-
focused interval history and medical decision-making of low complexity, typical time with patient 25 minutes. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the records support that the 
services were performed by a Registered Nurse and not a physician, PA, or NP as required. 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 pay for the home visit rendered on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression System. 
 
You asked the Plan to pre-approve Vertiflex Superion Indirect Decompression System. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Vertiflex Superion Indirect 
Decompression System. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The 
requested spacer is considered experimental. More research is needed to show safety and efficacy. Therefore, 
the enrollee does not meet criteria for the requested 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 Vertiflex Superion Indirect Decompression System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression 
System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided on May 19, 2020. 
 
You asked the Plan to pay for assistant at surgery services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says a registered nurse is not eligible for 
payment when providing assistant at surgery services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided 
on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin graft substitute. 
 
You asked the Plan to pre-approve skin graft substitute. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that skin graft substitute is only covered for certain 
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 skin graft substitute. Our reviewer says 
that the documentation does not support that the requested skin graft substitute is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a non-pressure chronic ulcer. There is no 
documentation provided that justifies the use of the skin graft type requested. It is considered experimental and 
there is no indication documented. Therefore, the enrollee does not meet criteria for the requested 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 skin graft substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin graft substitute.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 May 19, 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 on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had on June 26, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went to your doctor for a 
routine physical, which shouldn't have a copayment. The Plan denied your request. The Plan says you received 
services beyond what are part of a routine physical, which is why a copayment 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 $5 
copayment for visits with your PCP.  
 
Records show that you went to your doctor's office for an annual physical exam.  The medical records from 
that date of service show that in addition to the normal annual physical exam services, you also received a full 
assessment for allergic rhinitis for which you were prescribed Singulair.  This part of the evaluation is not a 
part of a normal annual physical exam, which is why the copayment was assessed. You have been asked to pay 
a $5 copayment for the office visit. 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 the office visit you 
had on June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. 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 laboratory services provided on June 18, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of area apheresis treatments and physician 
services for the enrollee. 
 
You asked the Plan to provide coverage for out of area physician services for the enrollee. You say that this 
treatment is medically necessary. The Plan denied your request. The Plan says that insufficient medical records 
were provided to show this service is urgently needed out of area at this time or that the enrollee meets the 
criteria required for this type of treatment.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for out of area care and for the 
treatment requested. The limited medical records provided do not show out of area care is required at this time. 
The diagnosis reported is hypercholesterolemia. The records provided do not show the enrollee has a diagnosis 
or indication for the requested treatment. Therefore, we decided that the Plan does not have to provide coverage 
for out of area apheresis treatments and physician services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fluid Flow (Fluid Flow(TM) and Fluid GF are 
amniotic liquid allografts derived from human amniotic tissue (stem cell) (Q4206 x2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided notes do not show that the patient has a condition which would warrant stem cell 
treatment. There is insufficient current high quality literature to support general use of stem cell treatment for 
osteoarthritis. Therefore, this request for stem cell treatment (Fluid Flow and Fluid GF) will be considered not 
medically necessary for this patient. 
 
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 the Fluid Flow (Fluid Flow(TM) and Fluid GF are amniotic liquid allografts derived from 
human amniotic tissue (stem cell) (Q4206 x2).