Persius/hicric huggingface dataset:
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 the enrollee is eligible for rehabilitation, and IRF is 
the level of care the enrollee needs in order to get better. The provider also says that if the enrollee stays in the 
hospital, she will get worse. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information they have about the enrollee's condition; the enrollee does not meet the requirements. 
 
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 patient does not require treatment by multiples therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician 
reviewer also found that while the medical record supports a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Our physician reviewer also found that 
medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the CT, lower extremity; without contrast material (CPT code 
73700). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the CT scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our physician reviewer 
found assuming this procedure is the one to be performed the CT of the knee is 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the CT, lower extremity; without contrast material (CPT code 73700).  
 
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 Gemcitabine, Rituximab, Oxaliplatin, Rituximab-abbs, 
Rituximab-pvvr, and Rituximab-arrx. 
 
You asked the Plan to pre-approve Gemcitabine, Rituximab, Oxaliplatin, Rituximab-abbs, Rituximab-pvvr, and 
Rituximab-arrx. You say that the services are necessary. The Plan denied your request. The Plan says based on 
the documentation provided, coverage criteria has not been met. 
 
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 Gemcitabine, Rituximab, Oxaliplatin, 
Rituximab-abbs, Rituximab-pvvr, and Rituximab-arrx. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested 
drug combination is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation.  
No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine, Rituximab, Oxaliplatin, Rituximab-abbs, Rituximab-pvvr, and 
Rituximab-arrx have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Gemcitabine, Rituximab, Oxaliplatin, Rituximab-abbs, Rituximab-pvvr, and Rituximab-arrx.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan follows Medicare rules. The rules also say that a PCD coded as E0675 to treat peripheral arterial 
disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine received on May 17, 2022. 
 
You asked the Plan to pay for the vaccine. You say that it's been ten years since you've had this vaccine. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine received on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a medically indicated procedure 
for the enrollee. The Plan denied your request. The Plan says this remains an experimental procedure for the 
enrollee's condition. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the Food and Drug Administration (FDA) Indications for Use, The 
Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency 
generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low 
back pain of at least six months duration that has not responded to at least six months of conservative care, and 
is also accompanied by features consistent with Type 1 or Type 2 Modic changes on a magnetic resonance 
image (MRI). 
 Detailed documentation is not evident regarding Modic type changes at all of the requested surgical levels. 
Additionally, there were/are multiple plausible pathologic sources of significant pain generation. The non-
radiating midline back pain, the noted pain-aggravating (prolonged activity including standing and prolonged 
sitting) and intact neurologic exam were/are all non-specific to any pathologic entities.  
 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Intracept intraosseous basivertebral nerve ablation at L3, L4, L5, and S1, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar spine fusion (CPT code(s): 22840 and 
22612). 
 
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 enrollee's records do not show that they will be undergoing decompression of the 
foraminal stenosis at L3-4. The Plan states the enrollee's records also do not show the levels involved in their 
scoliosis which would reveal which levels need to be fused. 
 
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 there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested lumbar spine fusion 
(CPT 22840 and 22612) possibly at level L3/4, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar spine fusion (CPT code(s): 22840 and 22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxycodone 5mg tablets. 
 
You asked the Plan to pre-approve the oxycodone tablets. You say that you need these medications to control 
your pain. The Plan denied your request. The Plan says this is self-administered and cannot be covered 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 oxycodone 5mg tablets.  
 
Benefits for the oxycodone 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTAC. The enrollee cannot be adequately cared for in the current skilled nursing facility. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for admission to a LTACH and at 
this time the enrollee is not stable for transfer. 
 
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 was admitted to the acute care hospital with pleural effusion, 
empyema/pneumonia, pneumothorax, requiring a video-assisted thoracoscopic surgery procedure, 
bronchoscopy and decortication, chest tube placement, intubation, and antibiotics. Recent notes describe the 
enrollee as now having been extubated, completed antibiotics, and tolerating room air but with persisting 
leaving from chest tubes.  
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
vertebrogenic low back pain. Detailed documentation is not evidence regarding Modic-type changes at all of 
the requested levels for the Intracept procedure. Additionally, there are multiple plausible pathologic sources of 
significant pain generation. The Intracept procedure is therefore not reasonable or medically necessary. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery and radiation therapy 
provided from March 11, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgery and radiation therapy. You say that you do 
not agree with the charges. The Plan denied your request. The Plan says the cost share has been applied 
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 $275 
copayment for each Medicare-covered outpatient hospital facility visit and a $60 copayment for each 
Medicare-covered visit for therapeutic radiation therapy. 
  You have been asked to pay a total of $1,338.92 for outpatient surgery and radiation therapy.  
 
Date of Service Service Allowed Amount Cost Per Contract Member Liability 
March 11, 2022 Clinic Visit $115.74 $275 $0 
March 22, 2022 Radiation Therapy $329.87 $60.00 $60.00 
March 22, 2022 Surgery $274.73 $275 $274.73 
March 24, 2022 Radiation Therapy $691.03 $60.00 $60.00 
March 24, 2022 Surgery $274.73 $275 $274.73 
March 28, 2022 Radiation Therapy $691.03 $60.00 $60.00 
March 28, 2022 Surgery $274.73 $275 $274.73 
March 30, 2022 Radiation Therapy $691.03 $60.00 $60.00 
March 30, 2022 Surgery $274.73 $275 $274.73 
Totals    $1,338.92 
 
Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. Radiation therapy falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 outpatient surgery and radiation therapy provided from March 11, 2022, to March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs surgery to be 
inpatient. The Plan denied your request. The Plan says this surgery can be done on an outpatient/observation 
basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our physician reviewer found the enrollee appears to be stable, and the documentation provided suggests 
the enrollee can have the procedure performed safely in an ambulatory center or observation status. There is no 
suggestion that the enrollee will require hospital services that would likely cross at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl. 
 
You asked the Plan to pre-approve Fentanyl. You say that you need this drug. The Plan denied your request. 
The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl.  
 Benefits for Fentanyl may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit on June 13, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share was applied 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 covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit on June 13, 2022.