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

 
We decided that the Plan does not have to pre-approve a genicular nerve injection (64454). 
 
You asked the Plan to pre-approve a genicular nerve injection. You say that the enrollee is a poor medical 
candidate for a total knee replacement, but they really need it. You also say that you do not see how the denial 
of genicular nerve blocks and radiofrequency ablations as investigational is accurate because you have been 
performing these procedures with excellent results. The Plan denied your request. The Plan says there is not 
enough medical evidence that shows the procedure is helpful and safe for knee pain. 
 
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 a genicular nerve injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of genicular nerve blocks and radiofrequency ablation is the 
subject of current ongoing clinical trials. Our reviewer also found that it is considered experimental at this time. 
 
 
 
 
 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 genicular nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve injection (64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has met the Medicare 
Guidelines for coverage for a power wheelchair. The Plan denied your request. The Plan says in order for the 
power wheelchair to be covered the documentation must show that the enrollee is unable to safely use a 
scooter. The Plan also says the records do not show that you are unable to safely use a power-operated vehicle 
(POV) or scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
 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 power wheelchair. Our reviewer says 
that a power wheelchair is not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the documentation does not indicate the mobility deficit cannot be overcome with a power scooter. The 
home evaluation indicates the enrollee was assessed in the home with a power scooter and was able to navigate 
the homestead, however a group 2 power wheelchair is being requested. Our reviewer also found that the 
criteria for a group 2 power wheelchair have not been 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and testing provided on 
February 17, 2022. 
 
You asked the Plan to waive the copayments for an office visit and testing. You say that this should be covered. 
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 $10 
copayment for outpatient diagnostic tests and a $50 copayment for a specialist visit.  
 
 
 
 
 You have been asked to pay a total of a $60 copayment for an office visit and testing. The testing falls within 
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The specialist 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 copayments for an office visit and testing provided on February 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 7, 2022, to July 27, 2022. 
 
You asked the Plan to pay for SNF care. You say that the admission was medically necessary. The Plan denied 
your request. The Plan says we did not approve the request because the information provided does not show the 
enrollee needed daily skilled nursing or skilled therapy services. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care was not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found from a nursing perspective, the enrollee received enteral nutrition and medications. 
The enrollee had stable vital signs and received wound care to a stage 3 sacral wound. The enrollee also had 
routine tracheostomy care. Regarding rehabilitation care services the enrollee received physical therapy and 
speech therapy. The enrollee was at a supervision to contact guard assist level with functional mobility 
including gait and required varying assist with activities of daily living skills. The enrollee did not have daily 
skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found that the enrollee did 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 pay for SNF care provided from July 7, 2022, to July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 28, 2022, to August 26, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says skilled nursing facility care is no 
longer required. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on 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 pay for SNF care provided from July 28, 2022, to August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (84439, 80061, and 84443) provided on 
August 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied 
your request. The Plan says these services were provided OON and the referring provided is OON as well. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services (84439, 80061, and 84443) 
provided on August 3, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, Carboplatin, and 
Cyanocobalamin. 
 
You asked the Plan to pre-approve Keytruda, Pemetrexed, Carboplatin, and Cyanocobalamin. You say that the 
enrollee has cancer and needs to be treated quickly. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and necessary. 
 
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 Keytruda, Pemetrexed, Carboplatin, 
and Cyanocobalamin. Our reviewer says that Keytruda, Pemetrexed, Carboplatin, and Cyanocobalamin are not 
medically reasonable and necessary for the enrollee. Our physician reviewer found the FDA has not stated that 
the requested drug 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 in the enrollee's clinical situation. Our 
reviewer found no literature from Medicare approved cancer journals were submitted for review. The elements 
of the coverage criteria are not satisfied. Our physician reviewer also found that 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 Keytruda, Pemetrexed, Carboplatin, and Cyanocobalamin have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, Carboplatin, and 
Cyanocobalamin.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology procedures provided to the enrollee on 
August 31, 2021. 
 
You asked the Plan to pay for the procedures. You say that you request that this claim be reprocessed for 
additional benefits on behalf of the enrollee. The Plan denied your request. The Plan says this is not medically 
necessary for the diagnosis and treatment of the enrollee's illness or injury 
 
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 procedures. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the comprehensive cardiac risk profile genetic testing was 
medically reasonable and necessary for the enrollee in this case. The documentation does not support that the genetic testing in this case was reasonably expected to impact the management and outcome of this enrollee. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology procedures provided to the enrollee on August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three dimensional (3D) rendering with interpretation and 
reporting (76376) provided on February 14, 2022. 
 
  You asked the Plan to pay for the 3D rendering with interpretation and reporting. You say that the medical 
records prove the service was medically necessary, and you would like this claim to be reprocessed towards 
payment. The Plan denied your request. The Plan says there was no documentation of an order for the 3D 
image nor documentation by the interpreting physician that the 3D interpretation was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for hospital-based services, it is expected that 
there should be an order for the 3D image.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 3D rendering with interpretation and reporting have not been met. Specifically, the provided 
documentation does not include an order for the 3D image, or a statement from the interpreting physician 
deeming the 3D interpretation was needed. Therefore, we decided that the Plan does not have to pay for the 
three dimensional (3D) rendering with interpretation and reporting (76376) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740) for tooth #20 and #29 provided on August 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you shouldn't be responsible for this 
bill because the services were medically necessary and causing you pain. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 29, 2020 for tooth 
#20 and on September 10, 2020 for tooth #29. Therefore, we decided that the Plan does not have to pay for 
crowns (D2740) for tooth #20 and #29 provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on August 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not have out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
eye exam at issue. We found no exception that would require the Plan to pay for the eye exam. Therefore, we 
decided that the Plan does not have to pay for the eye exam provided on August 16, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate or equal lens (V2784) and bifocal lens 
(V2200) provided on September 1, 2022. 
 
You asked the Plan to pay for the polycarbonate or equal lens and bifocal lens. You say that you were told you 
were told to pay $33.00 for glasses, and did not get new frames. You also say that you would like this claim to 
be considered for coverage. The Plan denied your request. The Plan says the polycarbonate or equal lens is not 
a covered benefit under your plan. The Plan also says that you have exceeded the limitations set in the 
subscriber agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every 2 years. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you purchased eyewear on June 
14, 2021, and your eyewear benefit has been exhausted. Based on this information, we decided that the Plan's 
rules for coverage of the polycarbonate or equal lens and bifocal lens have not been met. Therefore, we decided 
that the Plan does not have to pay for the polycarbonate or equal lens (V2784) and bifocal lens (V2200) 
provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor for a Freestyle Libre 2 continuous glucose 
monitor (CGM). 
 
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 criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that your insulin regimen requires 
frequent adjustments based on blood glucose monitor or CGM results. 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 a sensor for a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab), Carboplatin, and Alimta 
(Pemetrexed). 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Pemetrexed. The Plan denied your request. The 
Plan says the clinical value and effectiveness of continued treatment with Keytruda, Carboplatin, and 
Pemetrexed in the setting of disease progression on prior therapy with a programmed cell death protein 1 (PD-
1)/programmed cell death ligand 1 (PD-L1) inhibitor has not been demonstrated in the peer-reviewed literature. 
 
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 Keytruda, Carboplatin, and 
Pemetrexed. Our reviewer says that Keytruda, Carboplatin, and Pemetrexed are not medically reasonable and 
necessary for the enrollee. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of recurrent/metastatic multifocal lung adenocarcinoma, previously treated with an anti-PD-L1 drug and 
experienced progression of disease. The Food and Drug Administration has not stated that the requested drug 
regimen is indicated for the enrollee's condition. Our reviewer found that 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. Our 
physician reviewer also found that the elements of the coverage criteria are not satisfied, and 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 Keytruda, Carboplatin, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab), Carboplatin, and Alimta 
(Pemetrexed).