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

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. 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 proton beam therapy. Our reviewer says
that the requested proton beam therapy is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a
possible advantage of this expensive therapy. Any potential benefit or detriment of proton therapy over
standard IMRT for routine cases is an investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan
does not have to pre-approve proton beam therapy.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the deductible for the cataract surgery. We decided that the Plan does not have to waive the copayment for the cataract surgery.
You asked the Plan to waive the cost for the cataract surgery. You say that you feel the anesthesia should be included with the surgery and that you should not be charged extra. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the deductible for the cataract surgery.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that physician specialist services are excluded from the deductible.
The Plan says that you must pay $710.04 towards the deductible for the cataract surgery. Based on the plan contract, however, you cannot be asked to pay more than a $25 copayment for the cataract surgery. Therefore, we decided that the Plan has to reduce the cost of the cataract surgery from $710.04 to $25.
We also decided that the Plan does not have to waive the copayment for the cataract surgery.
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 $25 copayment for the cataract surgery. Therefore, we decided that the Plan does not have to waive the copayment for the cataract surgery.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
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 reviewer says that daily skilled services are not necessary. Our physician
reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee's condition does not meet severity of illness or
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria
are not met. 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 skilled nursing facility (SNF) services 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.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on the medical records, you do not require services at the LTACH that are not
already available at the current acute care hospital. The enrollee appears to be improving enough to expect the
current acute care hospital stay to be less than 25 days. There are no services available at the LTACH that you
require that are not already being received or available and covered at the current facility. There is no
advantage to transferring you at this point. Therefore, this request for LTACH services will be considered 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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says this drug is 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 Retacrit. Our reviewer says that
Retacrit is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found
that the enrollee has intermediate treatment related myelodysplastic syndrome. The use of epoetin agents such
as Retacrit in treatment, along with azacitabine, is not a standard of care to prevent anemia-related sided
effects. Retacrit is generally reserved as 2nd line therapy in higher risk disease that has failed standard therapy
and more for palliation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI scan provided on November 5, 2019.
You asked the Plan to pay for the MRI scan. 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 supported by the documentation.
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 73221 is magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s). We find that CPT code 73221 is not supported in the medical record. Specifically, the submitted documentation supports one unit of this code, which was previously approved and paid by the plan. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the MRI scan have not been met. Therefore, we decided that the Plan does not have to pay for the MRI scan provided on November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xofigo (Radium).
You asked the Plan to pre-approve Xofigo. You say that there is no evidence that the enrollee's disease course
diminishes his likelihood of benefit. The Plan denied your request. The Plan says Xofigo is not supported for
the enrollee's indication.
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 Xofigo. Our physician reviewer found
that Xofigo is being requested for metastatic castration resistant prostate cancer bones without pain or other
symptoms. The office visit specifically states he has minimal pain, including absence of pain in the right
shoulder where his most prominent uptake is. The vital signs indicate no pain. His medication list does not
include analgesics, except for a baby aspirin daily in the context of cardiac disease. Xofigo is FDA indicated
and compendium supported for use in symptomatic castration resistant prostate cancer. The enrollee does not
have symptoms. The study published establishing the utility of the agent specified regular use of analgesic
medication or treatment with external beam radiation required for cancer-related bone pain within the previous
12 weeks. The enrollee does not meet either criteria. The use of Xofigo is not listed as not indicated, not
recommended or not supported for the requested use in any of the compendia. Therefore, the requested drug is
not considered 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 Xofigo have not been met. Therefore, we decided that the Plan does not have to
pre-approve Xofigo (Radium).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the CardioMEMS heart failure monitor.
You asked the Plan to pre-approve the CardioMEMS monitor. You say that this has been shown to be effective
in clinical trials and should be allowed. The Plan denied your request. The Plan says there is not sufficient
evidence to support that this is a reasonable and necessary treatment.
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 CardioMEMS monitor. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has been
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met
since the device should still be considered experimental or investigational.
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 CardioMEMS monitor have not been met. Therefore, we decided that the
Plan does not have to pre-approve placement of the CardioMEMS heart failure monitor.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ALS emergency ambulance service (A0427) and ground mileage
(A0425) provided November 30, 2019.
You asked the Plan to pay for the ambulance service. You say that you are appealing the denial of payment and
have included the claim, the ambulance run report as well as the hospital inter-facility transfer form. The Plan
denied your request. The Plan says that ambulance services used for the transportation of a hospital inpatient to
another facility for diagnostic tests or special treatment is considered part of the inpatient admission and not
separately payable. Transportation, including transportation by ambulance, to and from another hospital or
freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where
the patient is an inpatient.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan must follow Medicare rules. The rules say that for the purpose of this
section "hospital inpatient" means a beneficiary who has been formally admitted it does not include a
beneficiary who is in the process of being transferred from one hospital to another. Where the patient is
transferred from one hospital to another, and is admitted as an inpatient to the second, the ambulance service is
payable under only Part B. You can find this rule in the Medicare Benefit Policy Manual Chapter 3, Section
10.4. A - Other Medical Items, Supplies and service - Exceptions, Ambulance service.
The records show that the enrollee was discharged from one hospital and was transferred to the airport for
emergency flight to be admitted to the receiving hospital. There is no evidence provided that the enrollee was a
registered inpatient at either facility at the time of this transportation. Nor was there evidence that the
discharging hospital is a part of the receiving hospital's system.
Based on this information, we decided that Medicare rules for coverage of the ambulance service have been
met. Therefore, we decided that the Plan has to pay for the ALS emergency ambulance service (A0427) and
ground mileage (A0425) provided November 30, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alendronate Sodium tablets.
You asked the Plan to pre-approve the Alendronate Sodium tablets. You say that the enrollee has been on Fosamax since 2017, the most recent bone density scan done in 2019, and is showing improvement on Fosamax. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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 Alendronate Sodium tablets.
Benefits for the Alendronate Sodium tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical placement of a dental implant provided on March 4,
2020.
You asked the Plan to pay for dental implant. You say that when you enrolled in this plan you were told that it
would cover routine and major dental work, and it makes no sense to you that this service would not be
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this procedure is not covered by the Plan's supplemental dental benefits.
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 pay for surgical
placement of a dental implant provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 4K score test for the enrollee.
You asked the Plan to pre-approve the test. You say that the enrollee wishes to avoid repeat biopsy at this
point. 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 test. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found a review of the submitted documentation dated 5/27/20 notes that the provider recommends a biopsy.
The enrollee is requesting a 4Kscore test. Documentation does not support the guidelines are met.
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 test have not been met. Therefore, we decided that the Plan does not have to
pre-approve the 4K score test for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 drug testing services provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular radiofrequency ablation (RFA) provided on
February 28, 2020.
You asked the Plan to pay for the genicular RFA. The Plan denied your request. The Plan says this is an
experimental procedure.
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 pay for the genicular RFA. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that genicular RFA is an experimental/investigational procedure that is the subject of on-going
clinical trials. This procedure is not part of any clinical practice guideline from a learned society. Therefore, it
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 genicular RFA have not been met. Therefore, we decided that the Plan does
not have to pay for the genicular radiofrequency ablation (RFA) provided on February 28, 2020.
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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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 already available at
the current acute care hospital. There is no advantage to transferring the enrollee at this time as all needs are
being met currently. Therefore, this request for LTACH services will be considered 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq and Bevacizumab.
You asked the Plan to pre-approve Tecentriq and Bevacizumab. The Plan denied your request. The Plan says
these drugs 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 Tecentriq and Bevacizumab. Our
reviewer says that Tecentriq and Bevacizumab are not medically reasonable and necessary for the enrollee in
this case. Our physician reviewer found that the combination of Tecentriq and Bevacizumab is for the treatment
of 1st line metastatic hepatocellular carcinoma. This enrollee has received at least 3 prior lines of therapy
including a prior PD-L1 inhibitor. 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 Tecentriq and Bevacizumab have not been met. Therefore, we decided that the
Plan does not have to pre-approve Tecentriq and Bevacizumab.