Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee is progressing slower than expected 
due to their pain and swelling.  The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for continued PT services.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee's range of motion and strength do not require ongoing 
formal therapy. The enrollee is ambulating without their cane. The requested additional therapy sessions do not 
require ongoing skilled professional therapist support. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 10 physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote afterloading high dose rate radionuclide 
interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels (77771). 
 
You asked the Plan to pre-approve remote afterloading high dose rate radionuclide interstitial or intracavitary 
brachytherapy, includes basic dosimetry, when performed; 2-12 channels. You say that this is medically 
necessary. The Plan denied your request. The Plan says more medical research is needed to support this is safe 
and effective for 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 remote afterloading high dose rate 
radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 
channels. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is not a standard 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 remote afterloading high dose rate radionuclide interstitial or intracavitary 
brachytherapy, includes basic dosimetry, when performed; 2-12 channels have not been met. Therefore, we 
decided that the Plan does not have to pre-approve remote afterloading high dose rate radionuclide interstitial 
or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels (77771).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services 
because you do not understand the non-payment. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the intraoral radiographic images are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic images (D0220 and D0230) provided on March 21, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of nab-paclitaxel. 
 
You asked the Plan to pre-approve nab-paclitaxel. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
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 nab-paclitaxel. Our reviewer says that 
the enrollee meets criteria for this nab-paclitaxel. Our physician reviewer found the requested use of nab-
paclitaxel is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. However, this use is 
supported by one of the major drug compendia and/or clinical research appearing in a Medicare-approved 
medical journal. The enrollee had a significant reaction to paclitaxel and nab-paclitaxel is often used in this 
setting as there is less risk of reaction. The documentation supports that this drug is safe and effective and 
otherwise medically reasonable and necessary 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 nab-paclitaxel have been met. Therefore, we decided that the Plan has to pre-
approve use of nab-paclitaxel.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 enrollee needs to go to a skilled nursing facility. 
The enrollee's life is in danger. The Plan denied your request. The Plan says the records do not show that you 
require daily skilled therapies or skilled nursing. The services you require 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 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 received oral medications and had stable vital signs. She underwent 
wound debridement and was treated with antibiotics. Regarding rehabilitation services, the beneficiary received 
physical therapy (PT) and occupational therapy (OT). The enrollee was at a supervision to contact guard assist 
level with functional mobility including gait to 250 feet. The enrollee required varying assist with activities of 
daily living (ADLs). The enrollee does not require skilled nursing or therapy services on a daily basis. This 
enrollee does 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99239 billed for date of service August 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were attached to reconsider for 
payment. The Plan denied your request. The Plan says that the records do not include the time spent. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
Both the Plan and the appeal state that medical records were submitted. The Plan did not include the medical 
records used in their decision to deny services. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for procedure code 99239 billed for date of service August 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 11, 2023. 
 
You asked the Plan to pay for the podiatry care. You say that you called the Plan and you were told your visit 
would be covered. You say that you did not know the visit would not cover corn and callus trimming. The Plan 
denied your request. The Plan says routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry care have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services 
provided on April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. The enrollee has moderate 
to severe both central and foraminal spinal stenosis, as well as history describing neurogenic claudication. The 
enrollee also has a diagnosis of radiculopathy. 
 
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 procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease or foraminal stenosis. The MRI shows spinal stenosis. The cause of back pain 
is not clear. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vegzelma. 
 You asked the Plan to pre-approve Vegzelma. You say that the enrollee has metastatic colon cancer and 
Vegzelma would be used for a lifesaving medication. The Plan denied your request. The Plan says the enrollee 
doesn't meet the requirement for coverage of the request for Vegzelma because they have not tried and failed 
Avastin or Mvasi. 
 
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 Vegzelma. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
metastatic adenocarcinoma of the duodenum. The requested medication is a new start. The provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives such as Avastin or 
Mvasi. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect 
from the Plan's preferred alternatives. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vegzelma have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vegzelma.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee needs the injection and has yet to receive it. 
The Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would likely be less 
effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on July 
6, 2022, through July 18, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on July 6, 2022, through July 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on September 10, 2022. 
 
You asked the Plan to pay for the ambulance services (A0428). You say that this was a medically necessary 
transport. You also ask to review the submitted medical records and pay for the transport service. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
  
We looked at the file and Medicare rules. The file includes evidence that the service at issue were reimbursed 
by the Plan on November 17, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date. Based on 
this information, we decided that the Medicare rules for the ambulance services have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 19, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the Plan paid claims for services provided 
by this physician for dates of service February 28, 2022 and June 20, 2022.  The Plan denied your request. The 
Plan says 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 Plan says that the Plan has also determined that these services 
are not urgent or emergent, nor were they approved in advance.  
 
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 on this date of service. The Plan did 
not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for physician's services provided on 
September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - three surfaces, posterior silver 
fillings (D2393) provided on February 20, 2023. 
 
You asked the Plan to pay more for resin-based composite silver fillings. You say that this should be covered. 
The Plan denied your request. The Plan says the fillings were paid correctly based on the groups contract-
amalgam allowance of equal size given to three posterior fillings, with the member responsible for the 
difference between silver and white. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for 
resin-based composite - three surfaces, posterior silver fillings (D2393) provided on February 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Injection, pembrolizumab, 1 mg (J9271). 
 
You asked the Plan to pre-approve drug, Injection, pembrolizumab. You say that the drug is to treat the 
enrollees squamous cell carcinoma of the cervix. The Plan denied your request. The Plan says not reasonable 
and necessary under Medicare guidelines. 
 
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 drug, Injection, pembrolizumab. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found not reasonable and 
necessary under Medicare guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug, Injection, pembrolizumab have not been met. Therefore, we decided that 
the Plan does not have to pre-approve drug, Injection, pembrolizumab, 1 mg (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on March 07, 2023. 
 
You asked the Plan to pay for the specialist office visit. You say that you are requesting reconsideration of the 
denied claim. 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 the specialist office visit 
provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36415, 82495, and 83018 billed for date of service 
September 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee only had one insurance. The Plan 
denied your request. The Plan says that the rules for payment have not been met. 
 
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 find that CPT code 36415, 82495, and 83018 have a status indicator of Q4. The services were not billed on 
the same claim as another separately payable service, which means separate payment is allowed. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 36415, 82495, and 83018 billed for date of service 
September 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.