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

 
We decided that the Plan does not have to pre-approve Pemetrexed and Pembrolizumab. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this regimen is not supported by the National Comprehensive Care Network (NCCN) 
guidelines. 
 
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 drugs. Our reviewer says that the 
requested drug regimen is not medically reasonable or necessary. Our physician reviewer found that all non-
small cell lung cancer patients considering neoadjuvant chemotherapy should have PDL1 testing as well as 
ALK and EGFR. Next generation sequencing is still pending. In addition, the standard immunotherapy in this 
setting is Nivolumab plus chemotherapy. The service is not reasonable or medically necessary and not likely to 
be safe and effective.  
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pemetrexed and Pembrolizumab.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87801 rendered on August 22, 
2022. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support the use of procedure codes 87801 x3 and 87150 x12 a there are more appropriate codes that are to 
the highest specificity for the labs being done. 
 We looked at this coder'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 procedure codes 87150 and 87801 rendered on August 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 for medical reasons, the enrollee is not ready to be 
discharged. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
SNF services. 
 
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 fell and fractured her humerus. She was admitted to the skilled 
facility on 4/11 and began therapy on 4/12. She made minimal progress. She was denied continued care after 
4/26. There are only records through 4/21/23. 
 
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 pay for ambulance services provided on January 4, 2023. 
 You asked the Plan to pay for ambulance services. You say that the enrollee was released from hospice on 
January 1, 2023. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 1, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on January 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
  You asked the Plan to pre-approve CT scan of the heart.. You say that the enrollee is hesitant to increase their 
medication due to the side effects. You say that there are concerns due to there being a high calcium burden 
seen on their lung CT. The Plan denied your request. The Plan says a CT scan of the heart is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan of the heart. Our reviewer says 
that a CT scan of the heart is not medically necessary. Our physician reviewer found that the enrollee is 
asymptomatic for cardiac disease and has been on statins. The enrollees low dose computed tomography scan 
showed server calcified plaque burden of the coronary arteries. While such finding signifies coronary 
atherosclerosis it is not a calcium score. However, based upon the description of severe calcification it must be 
assumed the plaque burden is significant and the utility of an absolute measurement seems inconsequential, as 
the burden has already been described as severe and the enrollee is on statins. Therefore, the medical necessity 
of the requested exam has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the heart.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you were in pain when doing 
physical therapy outside of the water. The Plan denied your request. The Plan says an MRI of the lumbar spine 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
you have chronic low back pain but are neurologically intact. Although the x-rays show degenerative changes 
and probable stenosis, physical therapy has been prescribed but not completed. Therefore, in the absence of 
attempts at physical therapy and red flags the medical necessity of the MRI has not been established. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 the enrollee's nursing, rehabilitation, and medical needs 
(combined complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary 
approach to rehabilitative care. While the enrollee may benefit from physical and occupational therapy, the 
enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a skilled 
nursing facility or outpatient therapy for gait training with prosthesis. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve procedure that affects nerves and use of a device 
called a percutaneous nerve stimulator (64555, L8679). 
 
You asked the Plan to pre-approve a percutaneous nerve stimulator. You say that the requested device is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested device is for 
auricular region placement and is not connected by an insulated lead to a receiver unit which is implanted 
under the skin at a depth not greater than 1/2 inch. Therefore, it is not reasonable and 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 a percutaneous nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. She has tried and failed 
conservative therapies and medication trials. This is an experimental/ investigational procedure. Therefore, the 
request is deemed not medically reasonable and 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 a percutaneous nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a nerve procedure that affects nerves and use of a device called a 
percutaneous nerve stimulator (64555, L8679).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says ongoing skilled care can be provided in an alternative 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 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 hospital discharge day management provided on October 19, 
2022.  
You asked the Plan to pay for hospital discharge day management. You say that the claim should be 
reprocessed because the charges are prior to the enrollee being discharged from the hospital and prior to 
hospice admission. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided on October 19, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery. 
 
You asked the Plan to pre-approve bariatric surgery.. You say that the records provided support the need for 
bariatric surgery. The Plan denied your request. The Plan says the record does not indicate that the enrollee 
needs to replace a defective device or correct a complication from the previous sleeve gastrectomy. 
 
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 bariatric surgery. Our reviewer says 
that bariatric surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a diagnosis of Morbid (severe) obesity due to excess calories. The enrollee underwent 
previous sleeve gastrectomy in April of 2019. The enrollee has been "unable to make any significant headway 
in terms of weight loss on her own, but she continues to demonstrate the motivation and desire to lose weight in 
order to improve her health." The enrollee is interested in having a gastric bypass, but reluctantly understands 
that insurance does not cover a revision. The case file does not contain documentation of clinical circumstances 
demonstrating reasonability and necessity (such as replacing a defective device or correcting a complication in 
a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bariatric surgery. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bariatric surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from November 1, 
2022, to November 30, 2022. 
 You asked the Plan to waive the copayment for a SNF visit. You say that you were quarantined twice during 
the SNF stay and had no access to rehabilitation care. 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 $0 
copayment for days 1 to 20 and a $180 copayment each day for days 21 to 100 for SNF care.  
 
You have been asked to pay a $1,855.44 copayment for a SNF visit. The total amount owed is less than the 
standard copayment for SNF care because your maximum out-of-pocket was met with the processing of this 
claim. This item/service falls within the SNF 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 a SNF visit provided from November 1, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 1, 2022. 
 You asked the Plan to pay for subsequent nursing facility care. You say that the physician is not paid by 
hospice. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on December 01, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that you have gone to this facility before, and you needed 
to find out what was going on with your health. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chest x-ray provided 
on December 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee should undergo a PET scan of the 
brain to provide valuable diagnostic information. The Plan denied your request. The Plan says a PET scan is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found that although the records provided 
suggested a diagnosis of AD, there were no evidence in the records that the enrollee met the diagnostic criteria 
for both AD and FTD. The base requirements of the NCD for coverage of the requested imaging study cannot 
be considered to have been met or satisfied in this case. Therefore, this did not meet Medicare criteria for 
coverage.  
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like reconsideration because the 
requested raised toilet is medically necessary. The Plan denied your request. The Plan says the requested raised 
toilet is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1686, L2624) rendered on November 11, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is evidence of misrepresented services. 
 
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 that there is no clear documentation available for review that supports the enrollee has significant right 
hip pain or any abnormal physical findings that would necessitate treatment with an orthosis. The requested 
orthosis does not appear appropriate to the enrollees medical needs and condition. 
 
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 orthotics (L1686, L2624) rendered on November 11, 2022.