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

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for coverage. 
 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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the member does not have any parental 
medication; complex wound care or nutrition given via a feeding tube.   Admission to a SNF for inpatient 
skilled rehab services is not medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Skilled Nursing Facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrathecal pump implantation. 
 
You asked the Plan to pre-approve an intrathecal pump implantation. You say that the records provided explain 
and support the need for this surgery. The Plan denied your request. The Plan says the enrollee does not meet 
the medical requirements for the device being requested. 
 
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 an intrathecal pump implantation. Our 
reviewer says that an intrathecal pump implantation is not considered medically reasonable and necessary in 
this case. Our physician reviewer found a trial of intra-thecal opioids is standard of care and is essential. The 
records do not show that a trial of intra-thecal opioid has been completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intrathecal pump implantation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an intrathecal pump implantation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on August 2, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not indicate how the test results will assist in managing the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found only the following codes should be billed for Cardiovascular Disease Screening: CPT code 80061 (Lipid 
panel) which includes CPT codes: 82465 (Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct 
measurement; high density cholesterol) and/or 84478 (Triglycerides). The review indicates that the services at 
issue in this case are 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair represented by code K0861, 
an electronic connection represented by code E2311, an expandable controller represented by code E2377, and 
an expandable controller harness represented by code E2313.  
You asked the Plan to pre-approve codes K0861, E2311, E2377 and E2313. You say that the enrollee's gait and 
balance have been severely affected by his neurological condition, leading to risk of falls. You say that the 
enrollee is unable to walk or use a single point cane, walker, manual wheelchair, or scooter to safely access his 
home environment. You say that the enrollee's mobility limitations affect his ability to perform certain 
activities of daily living by himself, including feeding and toileting. The Plan denied your request. The Plan 
says the records do not show that the enrollee meets the Medicare coverage criteria for the wheelchair and 
items being requested. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, myopathy or congenital 
skeletal deformity. 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 codes K0861, E2311, E2377 and 
E2313. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee has a neurologic disorder with functional deficits.  He meets criteria for use of a power mobility device 
but not a group 3 power wheelchair as he doesn't have a need for multiple power options.  The requested 
accessories are not medically necessary as he is not at high risk for pressure injuries or have any spasticity or a 
need for self-catheterization.  An expandable controller is not necessary as the requested power options have 
not been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes K0861, E2311, E2377 and E2313 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair represented by code K0861, an 
electronic connection represented by code E2311, an expandable controller represented by code E2377, and an 
expandable controller harness represented by code E2313.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services received on 
January 1, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the provider should 
bear the burden of this expense since they are the reason you had to go the emergency room. 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 $65 
copayment for each emergency room visit. If you are immediately admitted to the hospital, your cost-sharing 
amount for the emergency room visit will be waived. Records show that you were not admitted into the 
hospital. 
 
 
  You have been asked to pay $65 for emergency room services. Emergency room services fall within the 
Emergency 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 emergency room 
services received on January 1, 2022.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 has tolerated inpatient rehab 
services and continues to improve with daily skilled nursing and/or skilled therapy services. She could benefit 
from continued services at the current level of care. The enrollee has made slow progress with therapy, there is 
no indication that transfer to a skilled nursing facility is required. She can continue to receive skilled rehab 
services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services 
offered at a SNF that are not offered at an inpatient rehab facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures provided on July 20, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedures. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says a prior authorization was not obtained by the out-of-network 
provider for the services rendered on July 20, 2021. The Plan also says that the provider did not submit any 
documentation that the procedures were part of an emergency service. 
 
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 therapeutic procedures provided on July 20, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on December 1, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for trigger point injections provided to 
the enrollee on September 10, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of ultrasonic guidance for needle placement of 
trigger point injections for myofascial pain and spasm is considered experimental and investigational and have 
not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the clinical value and effectiveness of ultrasonic guidance for needle placement 
of trigger point injections for myofascial pain and spasm is considered experimental and investigational and 
have not been demonstrated in the peer-reviewed literature. The review has determined that there is no medical 
need for the ultrasonic guidance for the injections. 
 
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 pay for ultrasonic guidance for trigger point injections provided to the enrollee on September 10, 2021.
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 you would like reconsideration because the 
Keytruda is medically necessary. The Plan denied your request. The Plan says the enrollee's disease had prior 
progression on Opdivo 
 
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. Our reviewer says that the 
enrollee has progressed on prior immunotherapy. Our physician reviewer found the requested use of Keytruda 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch ultra test strip (A4253). 
 
You asked the Plan to pre-approve OneTouch ultra test strip. You say that the enrollee wants this particular 
brand and it is medically necessary for the enrollee's treatment for hyperglycemia. The Plan denied your 
request. The Plan says the records do not meet medical necessity guidelines for coverage. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. the requested glucose testing system is not the Plan preferred system. 
The Plan preferred systems are: Roche systems- Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek 
Compact Plus, and others; OR Trividia systems- TrueMetrix and TrueTrack. Also, per LCD L33822, blood 
sugar testing supplies should not exceed a 90 day supply. Based on this information, we decided that Medicare 
rules for coverage of OneTouch ultra test strip have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OneTouch ultra test strip (A4253).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
13, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were transferred to a 
different hospital because the type of doctor you needed to see was not available. You also say you should not 
have to pay $150 copayment because you did not ask to be transferred. 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 $150 
copayment for ground ambulance services.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$150 copayment for ambulance services. Ambulance services fall within the Ambulance Services 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 ambulance services provided on November 13, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen in the office for a follow-up 
visit for syncope. You say you would like the authorization approved. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on January 11, 2022, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor needs to send clinical notes or guidelines that shows why using Keytruda 
together with Paraplatin and Taxol will help. 
 
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 the drug. Our reviewer says that the 
requested drug regimen is not medically reasonable or necessary. Our physician reviewer found 
Pembrolizumab in not Food and Drug Administration (FDA) approved for advanced/metastatic urothelial 
cancer as first line therapy. Its use is supported after progression on platinum based therapy. Avelumab is FDA 
approved as maintenance therapy after platinum based therapy but not pembrolizumab. The service is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation provided to the 
enrollee on August 26, 2021. 
 
You asked the Plan to pre-approve the services. You say that the claim should be reconsidered for processing. 
The Plan denied your request. The Plan says this is considered investigational and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental/investigational procedure because of the wide variation in efficacy published in 
the peer reviewed literature. Therefore, the procedure is deemed not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation provided to the enrollee on August 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on February 5, 2022. 
 
You asked the Plan to pay for emergency room services. You say that you should not be responsible for the 
copayment. The Plan denied your request. The Plan says you have been charged the correct copayment amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $90 copayment for each emergency care visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 pay for emergency room services 
provided on February 5, 2022.  
 
Your complaint about the way you were treated and cared for is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.