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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. 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 care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar (L0180) provided on April 17, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical collar (L0180) 
provided on April 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pulmonary stress test provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for a pulmonary stress test. You say that you've had identical 
testing done before and its always been covered. The Plan denied your request. The Plan says the copayment 
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 $125 
copayment for a pulmonary stress test.  
 
 
 
 
 You have been asked to pay $103.98, which is less than the standard $125 copayment for a pulmonary stress 
test. A pulmonary stress test falls within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. The stress test is considered a diagnostic test that was performed at an outpatient hospital 
facility. 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 pulmonary stress test provided on 
December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation therapy visits and procedures provided from 
December 1, 2021, to December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiation therapy visits and procedures. You say that it was medically 
necessary to treat the enrollee and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 radiation therapy visits and procedures 
provided from December 1, 2021, to December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found although pembrolizumab is FDA approved, 
for this enrollee's lung cancer it is not reasonable or medically necessary as it is not felt to be safe or effective 
given his poor performance status. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of entropion. 
 
You asked the Plan to pre-approve repair of entropion. 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 follows Medicare rules. Medicare rules say that other eyelid surgeries may be considered 
reconstructive in nature for certain circumstances. 
 
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 repair of entropion. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record provided does not 
indicate that there is functional impairment or corneal and/or conjunctival injury. The record does not include 
photographs demonstrating functional impairment or corneal and/or conjunctival injury. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 repair of entropion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repair of entropion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for influenza virus vaccine provided on November 23, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for influenza virus vaccine. You say that the influenza virus vaccine has a $0 
copayment. The Plan denied your request. The Plan says the services under appeal were received from an out-
of-network provider without prior authorization from the Plan. 
 
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 influenza virus vaccine provided on November 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computerized corneal topography, 
unilateral or bilateral, with interpretation and report (92025) and the ophthalmic biometry (92136) provided on 
September 29, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $75.00 
copay for each covered diagnostic procedure or test at a network doctor's office.  
 
 You have been asked to pay a $75 copayment for the diagnostic tests provided. 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 computerized corneal topography, unilateral or bilateral, with interpretation and 
report (92025) and the ophthalmic biometry (92136) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography. 
 
You asked the Plan to pre-approve catheter placement in coronary artery(s) for coronary angiography. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 catheter placement in coronary artery(s) 
for coronary angiography. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and 
necessity for performance of cardiac catheterization. The medical records provided which are lacking 
information on clinical symptoms, past medical history and results of any prior cardiac imaging do not support 
the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter placement in coronary artery(s) for coronary angiography have not 
been met. Therefore, we decided that the Plan does not have to pre-approve catheter placement in coronary 
artery(s) for coronary angiography.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty and carotid 
stenting. 
 
You asked the Plan to pre-approve percutaneous transluminal angioplasty and carotid stenting. You say that 
this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous transluminal angioplasty services will 
only be covered for enrollees who are symptomatic with carotid artery stenosis of greater than 70%. 
 
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 percutaneous transluminal angioplasty 
and carotid stenting. Our reviewer says that the requested services are not medically reasonable and necessary. 
Our physician reviewer found a request is made for authorization for PTA and stent placement to address an 
asymptomatic, 70% narrowing in the right internal carotid artery. Guidelines are clear that such a procedure 
would be authorized only if there were accompanying symptoms or if the lesion narrowing were 80% or more. 
In their absence, PTA and stent placement would not be considered 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 percutaneous transluminal angioplasty and carotid stenting have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty and 
carotid stenting.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a revision sleeve gastrectomy. 
 
You asked the Plan to pre-approve a revision sleeve gastrectomy. You say that without the procedure, the 
enrollee will continue to gain weight and will not be able to have a full quality of life, good health, and proper 
lifestyle that he was achieving before. The Plan denied your request. The Plan says that this request is not 
medically necessary because the records show the enrollee had a previous weight loss surgery and there is no 
mention of any complications from that previous surgery. 
 
The Plan must follow Medicare rules. The Medicare rules say that repeat bariatric procedures may potentially 
be covered when clinical circumstances demonstrate reasonability and necessity.   
 
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 revision sleeve gastrectomy. Our 
reviewer says that a revision sleeve gastrectomy is medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee meets the criteria for bariatric surgery at this time with a Body Mass 
Index (BMI) that is 51 kg/m2, weight loss efforts and several obesity related health conditions. Our reviewer 
found that the patient had history of the lap band, which is a foreign device, it was removed in 2022 secondary 
to technical complications. Unlike other stapled procedures, such as sleeve gastrectomy or gastric bypass, the 
lap band does not work once removed from the body. Our physician reviewer also found that the patient does 
not have any sustainable weight loss tool and should be considered a candidate based on meeting primary 
guideline criteria. 
 
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 revision sleeve gastrectomy have been met. Therefore, we decided that the 
Plan has to pre-approve a revision sleeve gastrectomy.  
 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 Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for Gammagard to be covered under their Medicare Part B (medical) plan. 
 
The Plan follows Medicare rules. Medicare rules say that intravenous immune globulin (IVIG) is covered if all 
of the criteria listed in the Rules section above are met. 
 
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 Gammagard. Our reviewer says that the 
criteria for coverage for Gammagard is not met. Our physician reviewer found the enrollee does not meet all of 
the criteria listed above for coverage of Gammagard. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard (J1569).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device. 
 
You asked the Plan to pre-approve a vertiflex device. You say that the service at issue is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not medically necessary and it is 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental and more research is needed. 
 
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 vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vertiflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. 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 care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found as a practical matter, you did not require any 
skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.
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 inpatient rehabilitation is recommended by the 
therapist and the medical team. 
 The Plan denied your request. The Plan says authorization denied because IRF is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and there is lack of medical complexity, and lack of 
rehabilitation nursing needs. The documentation does not support the necessity for admission to an IRF. While 
you may benefit from physical therapy, speech therapy, and occupational therapy, your rehabilitation can be 
safely provided at a lower intensity and alternate setting such as in an SNF. 
 
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.