Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick system. 
 
You asked the Plan to pre-approve the requested services. You say that incontinence has broken down the skin. 
The Plan denied your request. The Plan says the documentation does not indicate you are unable to use 
standard incontinence supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that urological supplies are only covered under 
certain medical indications. 
 
 
 We looked at the file and Medicare rules. The records provided do not show that you have permanent urinary 
incontinence or permanent urinary retention. 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 Purewick system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression 
(PILD) procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested service have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD for LSS may only be covered under the 
context of a clinical trial. 
 
We looked at the file and Medicare rules. The case record does not indicate that the enrollee is participating in 
an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of a PILD 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a PILD 
procedure (0275T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of spondylosis without myelopathy or radiculopathy, 
lumbar region. One double-blind randomized study has shown that improvement with the Intracept procedure 
was not clinically significant when compared with a sham procedure. Additional studies suggest that the 
Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the 
published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is 
investigational at this time. Therefore, the enrollee does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat medial branch block. 
 
You asked the Plan to pre-approve a repeat medial branch block. You say that a repeat medial branch block is 
medically necessary. The Plan denied your request. The Plan says a repeat medial branch block does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 repeat medial branch block. Our 
reviewer says that a repeat medial branch block is not medically necessary. Our physician reviewer found the 
enrollee received zero pain relief from prior injection at L4/L5. There is no reason to repeat the blocks at a 
level where no pain relief was obtained. 
 
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 repeat Medial Branch Block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat medial branch block.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on March 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a medication injection provided on 
February 22, 2022, and on March 23, 2022. 
 
You asked the Plan to waive the coinsurance for a medication injection. You say that you are being charged for 
these services twice. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
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 in-network Medicare Part B prescription drugs. The allowed amount of this drug is $4041.78 
resulting in a coinsurance amount of $808.36 ($4041.78 x 20% = $808.36). 
 
 
 
 
 
 You have been asked to pay a $808.36 coinsurance for a medication injection. A medication injection falls 
within the In-Network Medicare Part B Prescription 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 coinsurance for a medication injection provided on February 22, 2022, and on March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Aranesp and Retacrit first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Procrit. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has iron deficiency anemia due to chronic blood loss. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member has been experiencing low back 
pain for an extended period of time. The Plan denied your request. The Plan says that the information provided 
fails to indicate that the enrollee meets requirements for coverage. 
 
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 requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. She is noted to not have had any physical therapy and was not currently taking any 
medications. Additionally, it is not clearly documented as to when the compression fracture happened. The x-
ray addendum noted there appears to be some level of sclerosis within the vertebral body suggesting the 
fracture may be subacute and/or healing. The documentation cannot confirm this T12 compression fracture is 
acute or subacute. In addition, there are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you need to see this 
provider to help with your new diet because your current diet is not working. The Plan denied your request. 
The Plan says you do not meet the Medicare criteria for medical nutrition therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a minimally invasive off-pump Maze procedure including a hybrid 
or convergent ablation procedure (33254, 33255, 33258, 33265, 33266) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the off-pump Maze procedure is considered experimental, 
investigational or unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The CONVERGE trial 
(Delugio 2020) demonstrated the superiority of this hybrid approach combining epicardial and endocardial 
ablation compared with an endocardial catheter ablation procedure alone. While the simpler endocardial 
catheter ablation procedure would be more appropriate for paroxysmal atrial fibrillation, proceeding directly to 
a convergent hybrid procedure would be acceptable because of the poor results of endocardial catheter ablation 
alone, with the frequent need to later carry out a convergent hybrid procedure. As a result, authorization for the 
performance of a convergent hybrid ablation procedure would be considered appropriate and reasonable in this 
patients clinical management. Our physician reviewer found that the enrollee's condition meets criteria for 
coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a minimally invasive off-pump Maze procedure including a hybrid or convergent ablation procedure 
(33254, 33255, 33258, 33265, 33266) for the enrollee.  
 
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 Tecentriq, Carboplatin, and Etoposide. 
 
You asked the Plan to pre-approve Tecentriq, Carboplatin, and Etoposide. You say that the requested 
Tecentriq, Carboplatin, and Etoposide are medically necessary. The Plan denied your request. The Plan says 
the requested Tecentriq, Carboplatin, and Etoposide are not medically 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 Tecentriq, Carboplatin, and Etoposide. 
Our reviewer says that the requested Tecentriq, Carboplatin, and Etoposide are not medically necessary. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of stage IV lung cancer. The 
record indicates that the enrollee's disease progressed while on maintenance guidelines. The Food and Drug 
Administration 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. The National Comprehensive Cancer Network guidelines discourages the use of the requested drug Tecentriq when progression has occurred while receiving it. No literature from Medicare 
approved cancer journals were submitted for review. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 Tecentriq, Carboplatin, and Etoposide have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Tecentriq, Carboplatin, and Etoposide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a CT scan and an injection provided on October 6, 
2021. 
 
You asked the Plan to waive the cost for a CT scan and an injection. You say that you did not know there 
would be a cost associated with this test and should not have to pay it. The Plan denied your request. The Plan 
says the cost applied was correct. 
 
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 $150 
copayment for a CT scan and 20% coinsurance for an injection for outpatient diagnostic tests and Medicare 
Part B prescription drugs.  
 
You have been asked to pay a $150 copayment for a CT scan and $0.90 coinsurance for an injection ($150 + 
$0.90 = $150.90). A CT scan and an injection fall within the Outpatient Diagnostic Tests and Medicare Part B 
Prescription 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 for a CT scan and an injection provided on October 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from March 24,2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for the SNF services. You say that that you did not want to stay the 
3 extra days, however they would not let you go. You say that you cannot afford it because of the COVID-19 
virus. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $188 
copayment per day for days 21 through 100 of skilled nursing facility (SNF) care. You previously received 15 
days of SNF care in January and February 2022. This SNF stay lasted 8 days, which are days 16 to 23 of the 
SNF benefit period, resulting in a copayment amount of $564. 
 
  
You have been asked to pay a $564 copayment for SNF services ($188 per day x 3 days = $564). SNF services 
fall within the Skilled Nursing Facility Care 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 the skilled nursing facility (SNF) services provided from March 24,2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the genetic testing. The Plan denied your request. The Plan says this 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 genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the clinical documentation shows that enrollee has previously undergone extensive testing 
for this condition and there is no documented family history supporting the presence of a genetic disease. The 
review has determined that the requested genetic testing 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $60 
copayment for in-network outpatient diagnostic tests.  
 
 
 
 
 
 
 
 You have been asked to pay a $60 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound provided on April 5, 2022.