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

 
We decided that the Plan does not have to pre-approve BMP infuse allograft for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the BMP/Infuse allograft in the setting of 
posterior lumbar spine fusion surgery has 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 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 that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to prove the efficacy 
of this allograft in the setting of (lumbar region) fusion. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested BMP infuse allograft, in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BMP infuse allograft for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the direct skilled nursing services of a registered nurse 
(RN) in the home health or hospice setting, each 15 minutes (CPT code G0299). 
 
You asked the Plan to pre-approve the home health services. You say that the enrollee is in need of home 
health due to a recent hospital stay. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because their records do not show that they are under the care of a physician or other 
allowed practitioner who has developed and certified a plan of care. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found the documentation does not support that the enrollee requires additional skilled nursing services 
to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing 
services to effectively provide treatment, care, and/or services in order to improve the enrollees condition, 
perform a maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee 
has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting, each 15 minutes (CPT code G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
from September 15, 2020, to December 14, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
the Plan to reconsider their decision. The Plan denied your request. The Plan says these supplies and services 
are considered routine or not supported in the medical records.  
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, the items and services that have 
been denied by the Plan with a status code of G are considered routine and their payment is included in the 
room and board charge. The remaining denied services are not supported by the medical records. Therefore, we 
decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
from September 15, 2020, to December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC) with associated inpatient hospital stay. 
 
You asked the Plan to pre-approve placement of a LAAC. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
satisfied for the required procedure. 
 
The Plan follows Medicare rules. Medicare rules say that placement of a placement of a left atrial appendage 
closure device (LAAC) requires that the enrollee be deemed suitable for short-term warfarin but deemed unable 
to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only 
covered as a second line therapy to oral anticoagulants. 
 
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 placement of a LAAC. Our reviewer 
says that the requested procedure is not medically reasonable and necessary according to Medicare rules. Our 
physician reviewer found that at issue is the medical necessity of implanting a LAAC device in this patient in 
whom there is elevated risk of thromboembolic stroke due to atrial fibrillation. While the enrollee has a history 
of a fall, there is no contraindication to anticoagulation. As such, guidelines would not support implantation of 
a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or medically 
necessary in this patients 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 placement of a LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC) with associated 
inpatient hospital stay.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational services are not covered by Medicare. 
 
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 that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate that the 
requested allograft is as safe and effective as the standard allografts. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested Novabone, allograft, morselized, or placement of osteopromotive material, for spine surgery, in 
this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft, morselized, or placement of osteopromotive material, for spine surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the requested treatment is medically necessary The Plan 
denied your request. The Plan says this treatment is not proven to be a better outcome for the enrollee's 
condition. This treatment is experimental. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the rationale for IGRT (with surface tracking) is written in generic/template format and does 
not specify why the enrollee specifically would need IGRT. As routine use of IGRT is not within accepted 
standards or care, the decision is unfavorable. Without a plausible rationale for the need of IGRT for the 
enrollee, IGRT would be furnished in accordance with accepted standards outside of special/exceptional 
circumstances- which the case records did not justify. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image-Guided Radiation Therapy (IGRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has been receiving skilled nursing services continuously for months 
in a long-term acute care hospital. The enrollee is in a chronic state and does not qualify for daily skilled 
nursing services as he has not been without skilled services for at least 60 days. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 that there is limited published, large-scale, long-term peer-reviewed literature that show bone growth 
stimulator to be an effective and/or safe treatment for patients over 60. Evidence is lacking that this device 
provides any significant benefit on fusion rates in this clinical setting overall. Further studies are needed in this 
clinical scenario. Additionally, the treating provider noted on 9/19/22 that she was healing as expected, but no 
appreciable interbody growth was seen on x-rays. Formal x-ray reports were not provided for review (with the 
radiologist's read.)  There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested electrical bone growth 
stimulator, in this case, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a bone growth 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 rehabilitation facility had been approved prior, 
but then was discontinued due to unknown reasons. The Plan denied your request. The Plan says the SNF care 
is not medically necessary, and your needs can be met at a lower level of care such as a nursing home. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. You do not require skilled nursing or therapy services daily. As a practical matter, you do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promacta. 
 
You asked the Plan to pre-approve Promacta. You say that the requested medication is medically necessary and 
supported by the records provided. The Plan denied your request. The Plan says this Medicare Advantage 
contract does not cover outpatient prescription drugs. The Plan says that the enrollee may have a separate 
commercial pharmacy benefit or Medicare Part D benefit managed by another carrier. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Promacta.  
 Benefits for Promacta 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 pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 3, 2021, to December 31, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not qualify for SNF coverage. The enrollee did not have 
documented skilled nursing needs.  The enrollee did not have documented skilled therapy needs. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs could, as a practical matter, 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 pay for skilled nursing facility (SNF) services provided to the enrollee from December 3, 2021, to December 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit you had with a chiropractor (code 99202) on 
April 22, 2022. 
 
You asked the Plan to pay for the chiropractic office visit. You say that your booklet says that chiropractor 
visits are a $10 copayment, which you paid. The Plan denied your request. The Plan says the office visit is not 
a covered service.  The Plan says that it covered the manual manipulation of the spine you received (code 
98940), minus your applicable copayment. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit 
you had with a chiropractor (code 99202) on April 22, 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 you are in need of continued skilled nursing level of 
care. The Plan denied your request. The Plan says your request for approval of continued admission in a SNF 
does not meet the requirements for approval. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that all inpatient functional goals have been 
met with exception of lower body dressing, thus skilled therapy services would still be necessary. You have 
multiple comorbidities that would require the assessment by a professional nurse for medical monitoring; 
however, there is no evidence that daily skilled services are still required on an inpatient basis.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ambulance ride provided on May 24, 
2022. 
 
You asked the Plan to waive the deductible for an ambulance ride. You say that you should only have a $100 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
deductible for ambulance services. You had not yet met your deductible at the time of this ambulance ride, 
therefor the $443.94 cost is upheld.  
 
You have been asked to pay a $443.94 deductible for an ambulance ride. This item/service falls 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 deductible for an ambulance ride 
provided on May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belrapzo. 
 
You asked the Plan to pre-approve Belrapzo. 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 Belrapzo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found acalabrutinib bendamustine and rituxan are 
not compendia supported or literature approved. The request with acalabrutinib is experimental/investigstional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Belrapzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Belrapzo.