Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that the enrollee has failed conservative 
treatment, and clinical findings support the medical necessity of this procedure. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because studies have not proven that this is 
helpful for treatment of 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 pre-approve genicular nerve RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and ablation are considered investigational and not medically 
necessary for the treatment of chronic knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99213) provided June 5, 
2020. 
 
You asked the Plan to pay for the office or other outpatient visit. You say that the services provided were 
medically reasonable and necessary. The Plan denied your request. The Plan says coverage extends only to 
treatment by means of manual manipulation of the spine to correct a subluxation. 
 
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 or other outpatient visit (99213) provided June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have 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 is a 99-year-old female with a 
past medical history of diabetes, atrial fibrillation and heart failure who presented to the acute hospital on 
November 3, 2021, with increased edema. While you do require skilled therapy services, there is no evidence 
that skilled nursing services are necessary. Based on the medical records provided daily skilled services are not 
required as the provided records describe no significant change in functional status compared to baseline. In 
conclusion, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on September 9, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary, and the 
testing was administered in a Clinical Laboratory Improvement Amendments (CLIA) approved facility.  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 drug testing provided on September 9, 2020, 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 June 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were not aware that you needed a referral. 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. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on June 30, 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 this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of monotherapy Keytruda for the 
enrollee's condition have not been demonstrated. 
 
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 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 64-
year-old female who has been diagnosed with squamous-cell carcinoma in 2015. In this case, the requested 
drug of Keytruda is not FDA-approved for the enrollee's diagnosis because driver mutation and PD-L1 status 
on recent biopsy still pending. In addition, the use of Keytruda is not supported by one of the major drug 
compendia or by clinical research that appears in an approved Medicare 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the doctor wanted to see you in the office to give the 
results of your bone density test. You say this should be covered by your insurance. 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. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on July 30, 2021, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, intraoral periapical x-rays, 
adjunctive pre-diagnostic test, prophylaxis, and topical application of fluoride provided on June 9, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, adjunctive pre-diagnostic 
test, prophylaxis, and topical application of fluoride. You say that you would like this claim to be reprocessed 
and paid because you cannot afford to pay this bill. The Plan denied your request. The Plan says the treating 
provider is an OON provider. The Plan also says that there is no coverage for when services are rendered by an 
OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation, intraoral periapical x-rays, adjunctive pre-diagnostic test, prophylaxis, and 
topical application of fluoride provided on June 9, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Methotrexate.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have 
skilled nursing or therapy needs that need to be provided on a daily basis in an inpatient setting. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and was treated for 
pulmonary edema. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, 
you were at a modified independent to supervision level with functional mobility. You required varying assist 
with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require 
skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress overlap. 
 
You asked the Plan to pre-approve a mattress overlap. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that a mattress overlap is covered when the enrollee 
has multiple stage 2 pressure ulcers located on the trunk or pelvis. 
 
We looked at the file and Medicare rules. Review of the file does not support that you have pressure ulcers of 
the trunk or pelvis. Based on this information, we decided that Medicare rules for coverage of a mattress 
overlap have not been met. Therefore, we decided that the Plan does not have to pre-approve a mattress 
overlap.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a pain 
management specialist on August 20, 2020. 
 
You asked the Plan to waive the copayment for the pain management office visit. You say that you are eligible 
for a yearly physical which was denied due to the way it was coded. The Plan denied your request. The Plan 
says you were charged this copayment 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 $15 
copayment for visits with a specialist.  
 
You have been asked to pay a $15 copayment for the pain management office visit. The records show that on 
this date of service, you did not have an annual physical- this was a visit with a pain management specialist for 
a follow-up for sacroilliitis. 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 office visit you had 
with a pain management specialist on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told you did not need referrals anymore. 
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 
record shows you were billed by the medical group which is out-of-network. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on May 17, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to be sent to a SNF for 
treatment and a full recovery. The Plan denied your request. The Plan says that the services the enrollee 
requires can safely be received at a different setting. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion interspinous spacer device. 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 Superion interspinous spacer 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Superion spacer is experimental. More research is needed to 
show safety and efficacy of the device. 
 
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 Superion interspinous spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
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 you need IRF care. The Plan denied your request. 
The Plan says the criteria for admission to an IRF are not met. The services you need can be received at a lower 
level of care. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you are not unable to use a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found you do not have a personal mobility deficit 
that impairs participation in MRADLs and your mobility deficit can be helped by the use of a walker, cane or 
manual wheelchair.  
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0801).