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

 
We decided that the Plan does not have to pre-approve 50 additional non-emergency transportation trips 
(A0120). 
 You asked the Plan to pre-approve the additional routine transportation trips. You say that you need more trips 
for dialysis treatments.  The Plan denied your request. The Plan says you currently have 16 trips remaining and 
you will have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 50 
additional transportation trips for your dialysis appointments. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve 50 additional non-emergency transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy with filguration, bladder instillation 
of anticarcinogenic agent, transurethral electrosurgical resection of prostate (TURP), and cystourethroscopy, 
with insertion of indwelling ureteral stent to be done in a hospital setting. 
 
You asked the Plan to pre-approve the services. You say that this is an intensive surgery, and you want it done 
at the hospital. The Plan denied your request. The Plan says the service is medically necessary but does not 
need to be performed at a hospital. 
 
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 enrollee's condition does not require that this procedure be done at a hospital, rather than the community surgery center approved by the plan. The records show that the enrollee can safely have these 
procedures at an ambulatory surgical center and will not require hospital admission for these procedures. 
 
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 cystourethroscopy with filguration, bladder instillation of anticarcinogenic agent, 
transurethral electrosurgical resection of prostate (TURP), and cystourethroscopy, with insertion of indwelling 
ureteral stent to be done in a hospital setting.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lemtrada injection. 
 
You asked the Plan to pre-approve a Lemtrada injection. You say that the request for Lemtrada injection is 
medically necessary. The Plan denied your request. The Plan says the enrollee did not meet the step therapy 
requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lemtrada injection. Our physician 
reviewer found that the Plan requires a trial of drug Ocrevus before they will approve Lemtrada. Our physician 
reviewer found that based on the medical records provided there is no indication that the enrollee has tried and 
failed the required drug. Our physician reviewer found that there is no indication that the Plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lemtrada injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Lemtrada injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
June 14, 2023, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found  this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of June 14, 2023, forward and could have been treated in a lesser 
restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of inpatient mental health care from June 14, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64624 x2). 
 
You asked the Plan to pre-approve the destruction by neurolytic agent. You say that there are many peer-
reviewed articles indicating Genicular Nerve Radiofrequency Ablation's are indicated for painful knee arthritis. 
You also say that the enrollee has tried and failed recommended treatments. The Plan denied your request. The 
Plan says this procedure is considered experimental and investigational or unproven for knee pain. 
 
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 destruction by neurolytic agent. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental therapy which is the subject of ongoing clinical 
trials.  
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 destruction by neurolytic agent have not been met. Therefore, we decided 
that the Plan does not have to pre-approve destruction by neurolytic agent (64624 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had a stroke and needs physical 
therapy as soon as possible to regain normal functions. The Plan denied your request. The Plan says the 
medical records do not indicate complex medical needs. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 Ensure (B4150). 
 
You asked the Plan to pre-approve Ensure. You say that the enrollee cannot eat solid foods, and Ensure is one 
of the only foods that the enrollee can tolerate and swallow. The Plan denied your request. The Plan says this is 
a request for liquid food (Ensure) to be taken by mouth (oral). The Plan also says liquid food when taken by 
mouth is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure (B4150).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 05, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you believed this provider was in-network. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 an office visit provided on December 05, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Action Trackstander TR power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you just changed to this plan. You say 
that you were working with your old insurance for coverage for this power wheelchair. You also say that you 
want this to be covered. The Plan denied your request. The Plan says the wheelchair is being requested for use 
outside of the home and therefore is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the Action Trackstander TR power wheelchair.
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 Plan denied your request. The Plan says the 
enrollee does not meet the criteria for skilled nursing facility admission. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 pre-approve bilateral sacral radio frequency ablation. 
 
You asked the Plan to pre-approve bilateral sacral radio frequency ablation. You say that bilateral sacral radio 
frequency ablation is medically necessary. The Plan denied your request. The Plan says bilateral sacral radio 
frequency ablation 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 bilateral sacral radio frequency 
ablation. Our reviewer says that the requested bilateral sacral radio frequency ablation is not considered 
medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral 
branches is considered experimental/investigational because of the wide variation in efficacy reported in the 
literature. 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 bilateral sacral radio frequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral sacral radio frequency ablation.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 1, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says for a facility to receive reimbursement for a Medicare 
member, the facility must be enrolled to participate in the Medicare program.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit  have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (GAE). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 this is considered an experimental and investigational therapy at this time. The request, therefore, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve geniculate artery embolization (GAE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy of veins.  
 
You asked the Plan to pre-approve sclerotherapy of veins. You say that sclerotherapy of veins is medically 
necessary. The Plan denied your request. The Plan says the requested sclerotherapy of veins is cosmetic and 
does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 sclerotherapy of veins. Our reviewer 
says that the requested sclerotherapy of veins is not medically necessary. Our physician reviewer found the 
documentation does not meet coverage criteria. You have undergone saphenous ablation with good result and 
resolution of symptoms. There is no documentation of significant persistent symptoms or varicose bleeding. 
Prophylaxis against future bleeding is not a coverable indication and that risk was likely mitigated by the 
saphenous ablation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy of veins have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sclerotherapy of veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept intraosseous nerve ablation procedure. You say that you need 
some relief of your back pain and to be able to function at a higher rate than you currently are functioning. You 
say that during the last few years, you have had two back surgeries, spine injections, physical therapy, and 
spine  ablation and none of them have given you relief. The Plan denied your request. The Plan says the 
Intracept intraosseous nerve ablation procedure does not meet the Medicare coverage guidelines. 
 
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 Intracept intraosseous nerve 
ablation procedure. Our reviewer says that the requested Intracept intraosseous nerve ablation procedure is not 
considered medically reasonable and necessary in this case. Our physician reviewer found   
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 Intracept intraosseous nerve ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation 
procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ultrasound elastography for elevation of liver 
enzymes. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says in order to approve this request, clinical information will need to be submitted by the 
provider for review. 
 
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 the available documentation in the case file does not support that ultrasound elastography is 
medically reasonable and necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ultrasound elastography for elevation of liver enzymes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 28, 2022.