Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve the requested item. You say that the batter y is necessary. The Plan denied 
your request. The Plan says the request is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure 
(CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that the enrollee's previous treatment was for 
localization and is not a second line treatment for metastatic cancer. You say that this is the first line of 
treatment for the enrollee's metastatic cancer. The Plan denied your request. The Plan says continuation of 
Nivolumab is not supported when disease progression is documented. The Plan says that the enrollee has had 
extensive disease progression with multiple new metastatic lesions noted, while being treated with Nivolumab 
alone. 
 
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 Nivolumab. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the use of Nivolumab is not FDA-
approved for the enrollee's diagnosis because there has been progression of disease while on Nivolumab. The 
use of Nivolumab in this scenario is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) and office visit (99213) 
provided on May 17, 2022, by a chiropractor. 
 
You asked the Plan to pay for the therapeutic exercises and office visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says services other than manual 
manipulations of the spine to correct subluxation are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulations of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110) and office visit (99213) provided on 
May 17, 2022, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request has not been shown to provide a clear long-term benefit. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She had sacroiliac (SI) joint injections on June 29, 
2022, with 100% pain relief for one day. The enrollee had RFA of the right SI joint with good results. The 
request is for RFA of the left SI joint. RFA of the SI joint is considered experimental/investigational because of 
the wide variation in efficacy. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Orthovisc. 
 
You asked the Plan to pre-approve a tier exception for Orthovisc. The Plan denied your request. The Plan says 
tier exception reviews are not available for Part B drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Orthovisc have not been met. Specifically, tier exceptions do not apply to Part 
B drugs. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on September 15, 2021, to 
September 22, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for each Medicare-covered visit for podiatry services. Covered services include diagnosis and the 
medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). Routine 
foot care (limit of 6 nail debridement and 6 callous removal per plan year) for members with certain medical 
conditions affecting the lower limbs, such as diabetes with compromised circulation. There were two visits. 
$40 x 2 = $80. Therefore, resutls in the total cost sharing amount of $80. 
 
 
 
 You have been asked to pay a $40 copayment for each office visit. This item/service falls within the Podiatry 
services 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 office visit on September 
15, 2021, to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the operating room services provided on 
May 16, 2022, June 2, 2022, and June 30, 2022. 
 
You asked the Plan to waive the copayments for the operating room services. You say that you were told that 
only 1 copayment would be charged for all the dates of services. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. Also, the Plan confirmed the enrollee's call history and there were no 
calls made to the Plan to indicate 1 copayment would apply for all dates. 
 
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 $375 
copayment for in-network surgery services at an outpatient hospital. For each date of service there was a $375 
copayment applied. There was a total of 3 visits and the total copayment for 3 dates of service was $1,125 
($375 copayment x 3 dates of service). 
 
  You have been asked to pay a $1,125 copayment for the operating room services. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 copayments for the operating room services 
provided on May 16, 2022, June 2, 2022, and June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch identified with code 64640. 
 
You asked the Plan to pre-approve destruction by neurolytic agent; other peripheral nerve or branch. You say 
that you disagree with the Plan's 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 destruction by neurolytic agent; other 
peripheral nerve or branch. 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 post herptic neuraglia. 
The requested use for Qutenza. This medication is approved for this use, but it is not an injectable. Many 
practitioners inject a local anesthetic prior to the application of the patch, but that is a different code. The code 
requested is incorrect. Therefore, the requested services are not a covered benefit. 
 We looked at this physician's review, the file, and Medicare rules. Review of the file shows that the Plan has 
approved the requested patch, Qutenza. Qutenza is not an injected medication, so the requested code is not 
covered. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic 
agent; other peripheral nerve or branch have not been met. Therefore, we decided that the Plan does not have to 
pre-approve destruction by neurolytic agent; other peripheral nerve or branch identified with code 64640.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services provided on June 20, 2022. 
 You asked the Plan to pay for the laboratory testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this is a non-covered 
screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory testing services, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory testing services provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve the requested item. You say that there are continued outages due to the pat 
hurricane. The Plan denied your request. The Plan says the request is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a backup battery for a continuous positive airway pressure (CPAP) device was requested. 
The item at issue does not serve a purpose that is primarily medical in nature. Therefore, we decided that the 
Plan does not have to pre-approve a backup battery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are not 
demonstrating any ongoing skilled needs 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that you are at a standby assist level for sitting up, contact guard assist for standing, minimal assist for 
walking, and contact guard assist for toileting. You do not have documented skilled nursing or skilled therapy 
needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of 
your condition. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the denied regimen is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation does not support that the enrollee has 
no disease progression after definitive concurrent chemoradiation, as chemoradiation has not been started yet. 
 
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 Imfinzi. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Imfinzi is not FDA-
approved for the enrollee's diagnosis, as he has not yet shown a response to chemotherapy and radiation. The 
use of the requested drug is not supported by one of the major drug compendia or by clinical research that 
appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 a PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found according to the applicable 
NCD, a PET/CT for the evaluation of dementia is only covered in individuals who meet diagnostic criteria for 
both AD and FTD. In this case you are not noted to meet criteria for both AD and FTD. The provider's notes do 
not otherwise readily suggest the presence of either let alone both conditions. In this setting the basic 
requirement for coverage of this service as set forth by the NCD would not be met. In as much, this service 
would not be 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 a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a brain imaging, positron emission tomography (PET); metabolic evaluation 
(78608).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diazepam. 
 
You asked the Plan to pre-approve Diazepam. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is self-administered and does not fall under Part B 
coverage. The Plan says that they do not administer a Part D pharmacy benefit for the enrollee. 
 
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 Diazepam.  
 
Benefits for Diazepam 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like inpatient rehabilitation because it is 
difficult for you to move around, and you are in pain. You say that you feel being at home instead of inpatient 
is causing you to be worse. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 on review of available records, you are medically stable and have no complex 
nursing or rehabilitation needs. While you may benefit from physical and occupational therapy, your 
rehabilitation needs can be safely met in an alternate and low intensity setting such as in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not ready to go home yet and require skilled 
nursing care. You say that you need to be somewhere you can continue to gain strength. The Plan denied your 
request. The Plan says you are at or near your baseline functional status for most activities and any residual 
condition deficits can be safely and effectively addressed at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of 
service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
31, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that the enrollee was not 
aware of any copayment and does not have the means to pay. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance transportation. This item/service falls within the 
ambulance services 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 ambulance 
transportation provided on May 31, 2022.