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

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prefabricated post and core (D2954) and a re-cement crown 
(D2920) provided by a participating provider on July 8, 2021. 
 
You asked the Plan to pay for prefabricated post and core and a re-cement crown. You say that the enrollee 
would appreciate the Plan reimbursing me with any credit due. The Plan denied your request. The Plan says 
major dental services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for prefabricated post and core (D2954) and a re-cement crown (D2920) provided by a participating provider on 
July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection procedure for anesthetic, 
steroid, and/or other therapeutic agent to the sacroiliac joint; with or without arthrography (G0260) provided on 
May 26, 2021. 
 
You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you received a back 
injection in your sacroiliac joint which you have had done many times. The provider billed it as outpatient 
surgery, and you think it was only an injection. You say you have paid this before from a previous injection, 
but it just adds up. The Plan denied your request. The Plan says the cost-share was processed 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 $290 
copayment for Outpatient Surgery including services provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $290 copayment for a sacroiliac joint injection. Sacroiliac joint injections fall 
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 copayment for an injection 
procedure for anesthetic, steroid, and/or other therapeutic agent to the sacroiliac joint; with or without 
arthrography (G0260) provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 liquid biopsy coded 0242U provided on 
June 29, 2021. 
 
You asked the Plan to pay for the Guardant 360 liquid biopsy. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant 360 testing is only covered for certain 
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 pay for the Guardant 360 liquid biopsy. Our 
reviewer says that the documentation does not support that the Our physician reviewer found the enrollee has a 
diagnosis of lung cancer with metastases to the brain. During the course of the enrollee's treatment, the enrollee 
had a biopsy performed on June 16, 2021. There is no documentation submitted showing that there is not 
enough tumor tissue to have genetic testing or that it is medically contraindicated. The review has determined 
that the documentation did not show that the enrollee met criteria for the services rendered. The documentation 
did not show that there was not enough tumor tissue to have genetic testing or that it is medically 
contraindicated. 
 
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 Guardant 360 liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant 360 liquid biopsy coded 0242U provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta for the enrollee. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the requested drug would be deemed a routine cost of the clinical trial.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Neulasta as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Neulasta for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cardiac surgical services (33285) provided 
on June 29, 2021. 
 
You asked the Plan to waive the coinsurance for cardiac surgical services. You say that the services should be 
covered as you were unaware that the cost would be so high. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services rendered. 
 
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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.   
You have been asked to pay a 20% coinsurance for cardiac surgical services (20% of $8149.65 is $1,630) 
Cardiac surgical services fall 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 coinsurance for cardiac surgical services 
(33285) provided on June 29, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status, 
gastrointestinal bleeding, anemia, encephalopathy, and in hospital cardiac arrest. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) provided July 15, 2021. 
 
You asked the Plan to pay for the Tetanus vaccine. You say that you were not aware of these charges until 3 
weeks later. Usually, all the vaccines you have received were entirely free of charge. You had no idea of the 
charge otherwise you would not have allowed it. The Plan denied your request. The Plan says the claim has 
been identified as a Part D injectable and not payable under Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus 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 Tetanus 
vaccine. Therefore, we decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided July 15, 2021.  
 
Benefits for the Tetanus vaccine 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued care and coverage at a skilled nursing facility 
(SNF). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no requirement for daily 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 pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you no longer 
qualify for SNF coverage. You do not have documented skilled therapy or skilled nursing needs. You have 
reached a plateau in function given your enrollee's weight bearing restriction. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a 
practical matter, can be provided at a lower 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued care and coverage at a skilled nursing facility (SNF).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 26, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the 
enrollee on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the Triamcinolone Acetonide injections 
you received during specialist office visits from July 21, 2021, to May 21, 2121. 
 
You asked the Plan to waive the cost sharing for the Triamcinolone Acetonide injections and specialist office 
visits. You say that you are not happy with this cost sharing and you don't know if it is legal for the Plan to 
charge you. The Plan denied your request. The Plan says you were charged this cost sharing 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 20% 
coinsurance for Medicare Part B drugs and a $50 copayment for services with a specialist.  
 You have been asked to pay 20% coinsurance for the Triamcinolone Acetonide injections and a $50 copayment 
for each of the specialist office visits. The Triamcinolone Acetonide injections falls within the Medicare Part B 
drugs 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 cost sharing for the Triamcinolone Acetonide 
injections you received during specialist office visits from July 21, 2021, to May 21, 2121.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genesight testing (81291, 81479) provided on June 8, 2021. 
 
You asked the Plan to pay for Genesight testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that unless the record reflects that the treating 
clinician has already considered non-genetic factors to make a preliminary drug selection, pharmacogenomics 
(PGx) testing is not considered reasonable and necessary. The rules also say for Medicare to consider coverage 
and payment for any item or service, the information submitted by the supplier or provider must corroborate 
the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria 
have been met. 
 
We looked at the file and Medicare rules. Although the order for this testing marked that the treating physician 
already considered non-genetic factors, medical records were not submitted that document and confirm this 
information. Based on this information, we decided that Medicare rules for coverage of Genesight testing have 
not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81291, 81479) 
provided on June 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (fixed wing) (A0430) and fixed wing air mileage (A0435) provided on January 29, 2021. 
 
You asked the Plan to pay for the transportation services. You say that this was clearly a medical necessity. 
You also say that the physician ordered an air ambulance transport. The Plan denied your request. The Plan 
says the enrollee was not transported to the nearest facility as required by Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the 
patient is transferred is the nearest one with appropriate facilities. 
  
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation services have not been met. Specifically, the enrollee was not transported to the 
nearest facility as required by Medicare guidelines. Therefore, we decided that the Plan does not have to pay 
for the ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing 
air mileage (A0435) provided on January 29, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 
 
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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there has been no decline from the previous level of function. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage, as 
you do not have documented skilled therapy or skilled nursing needs. There is no acute decline in function. 
There is no ability to partake in skilled therapy. Daily skilled services are not shown to be required to establish 
a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 
be provided at a lower 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).