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

 
We decided that the Plan does not have to pre-approve use of Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there is no record of ferritin greater than or equal to 100 nanograms per 
milliliter or transferring saturation level greater than or equal to 20%. 
 
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 Epogen. Our reviewer says that the 
enrollee does not meet the criteria for use of Epogen. Our physician reviewer found Epogen is Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. However, the documentation does not support that 
the drug is safe and effective and otherwise reasonable and necessary for the enrollee. The file does not contain 
clinical documentation of symptomatic anemia. The file does not contain clinical documentation that iron 
deficiency and blood loss have been ruled out. The available documentation is insufficient to demonstrate 
medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Epogen.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment 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 reduce the copayment for the left eye cataract surgery performed by an in-network 
provider on February 22, 2022. You say that this cost-sharing should be lower. The Plan says that this cost 
sharing was charged correctly. 
 
 We decided that the Plan has to reduce the copayment for the cataract surgery.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $395 copayment for each in-network Medicare-covered 
outpatient surgery at an outpatient hospital facility. The Plan says you must pay a $1081.17 coinsurance cost-
share for the in-network outpatient hospital surgery services. Based on the Plan contract, however, you cannot 
be asked to pay more than $395 for in-network outpatient hospital surgery services. Therefore, we decided that 
the Plan has to reduce the copayment for the in-network outpatient hospital surgery services.  
 
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 $395 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
Cataract surgery falls within the in-network outpatient hospital surgery services benefit category. This means 
that you are responsible for a $395 copayment 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no medical reason the enrollee needs the procedure. 
 The Plan follows Medicare rules. Medicare rules say that a kyphoplasty procedure is 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 is being treated for a wedge compression fracture. She presented noting she is 
doing very well with minimal pain that is well controlled with acetaminophen only. The exam reveals vertebral 
spine pain. Strength and sensation are intact. It was noted on the computed tomography (CT) scan to show the 
bones are diffusely osteopenic. There is a degree of retropulsion of bone noted. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
Additionally, the exam indicates that she is doing well with minimal pain. The rationale for the requested 
procedure is not evident. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested kyphoplasty, in this case, 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty services.
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. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's current 
medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week 
for the ongoing management of any active or acute exacerbation of chronic medical conditions. 
 
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 the enrollee is unable to tolerate intensive therapy.  
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
unproven procedures are not covered by Medicare. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. The previous exam is noted to be consistent with axial back pain with some radiation of pain into 
the lower extremities. Current evidence based medical guideline and peer reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of a lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L4/5, in this case, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of congenital 
interatrial communication. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request 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 requested services. Our physician 
reviewer found that the enrollee had a stroke in 2016 and in 2022. An echocardiography has shown a patent 
foramen ovale (PFO) with normal right and left sided chambers size and no evidence of intramural thrombus. 
There is no echo evidence of cardiac chamber dilatation, or significant left to right shunt; nor is the enrollees 
age 60 or less. As such, guidelines would not support the need for a PFO closure device. In summary, there is 
insufficient documentation to support the medical necessity for the requested PFO closure in this enrollees 
clinical management. 
 
 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 a percutaneous transcatheter closure of congenital interatrial communication.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service April 16, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service April 16, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that your husband is failing to thrive needs to get back to 
therapy this will motivate your husband with the 3 hours of physical therapy every day. The Plan denied your 
request. The Plan says your husbands ongoing skilled therapy and nursing needs can be provided safely at a 
lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health 
care, or in a long-term care setting. 
 
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 medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria 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 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Minuteman G3R interspinous device 
(20930, 22840, 22612). 
 
You asked the Plan to pre-approve implantation of a Minuteman G3R interspinous device. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says the requested 
services are experimental/investigational. 
 
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 implantation of a Minuteman G3R 
interspinous device. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Minuteman device is experimental. More research 
is needed to demonstrate its safety and effectiveness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a Minuteman G3R interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a Minuteman G3R 
interspinous device (20930, 22840, 22612).
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. 
 
You asked the Plan to pre-approve IRF care. You say that you require a lot of assistance to get out of bed and 
walk, if you are discharged to home it will be difficult to get the assistance you need. The Plan denied your 
request. The Plan says your records do not show that you have complex rehabilitation needs requiring frequent 
evaluation by a rehabilitation doctor, medically necessary care may be provided safely in a different level of 
care. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. 
 
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.
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. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission has been correctly denied. 
 
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 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.  
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.
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 need skilled nursing services. The Plan denied 
your request. The Plan says this request has been correctly denied. 
 
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 you have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) supplies 
provided to the enrollee on August 12, 2022. 
 
You asked the Plan to pay for the supplies. You say that you were told the order was not covered. The Plan 
denied your request. The Plan says there is evidence of misrepresented services. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the supplies have been met. The 
provider did not send in an order for these supplies. The services cannot be verified.. Therefore, we decided 
that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) supplies provided to 
the enrollee on August 12, 2022.
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 the services are necessary to help the enrollee gain 
her mobility back before returning home. The Plan denied your request. The Plan says the records do not show 
the enrollee needs skilled nursing service on a daily basis and in an inpatient setting. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) device 
(E0730), provided on August 3, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says there is no evidence to support the ordering provider ordered this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. there is no evidence to support the ordering provider ordered this item. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve 
stimulator (TENS) device (E0730), provided on August 3, 2022.