Persius/hicric huggingface dataset:
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 physical, occupational and speech 
therapy and medical follow up. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for admission to a skilled nursing facility. 
 
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. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollee can complete their current course of care before being 
discharged to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed all other pain 
management interventions. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the requested service is not indicated for the enrollee's condition. There is no trial of back 
fracture bracing. Therefore, the request is not medically reasonable and necessary at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on November 28, 2022. 
 
You asked the Plan to pay for the injections. 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 injections provided 
on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the pneumatic compressor. You say that there are no other provider that can 
provide this specific device. The Plan denied your request. The Plan says there are network providers who can 
provide this device. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The Plan contract 
says the enrollees POS benefit only applies to nonMedicare covered dental services covered by the plan. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the pneumatic compressor to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
imaging. 
 
You asked the Plan to pre-approve the requested services. You say that you are shaking badly. The Plan denied 
your request. The Plan says no rationale has been provided for ordering the imaging.  
 
The Plan follows Medicare rules. Medicare rules say that SPECT imaging is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that you have a several month history of mild bilateral hand tremors; no cogwheeling. A 
dopamine transporter (DaT) SPECT scan has been requested. Such a scan can be used to differentiate between 
essential tremors and Parkinson's disease. However, no discussion concerning the necessity for the requested 
DaT SPECT scan has been found in the submitted records. Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve single photon emission computed tomography (SPECT) imaging.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve additional hours for home health aide services. 
 
You asked the Plan to pre-approve the additional aide service hours. You say that you had 3 surgeries in less 
than 2 months and are now having radiation for chemotherapy. You also say that you are feeling weak and are 
not being able to do things by myself.  The Plan denied your request. The Plan says that the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 additional aide services. Our 
reviewer says that the services are medically reasonable and necessary. Our physician reviewer found you have 
a history of breast cancer and continue to require chemotherapy. You are noted to be weak and require personal 
assistance with mobility and performing daily activities, including grooming, bathing, and toileting. Therefore, 
continued home health aide assistance is medically 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 additional aide services have been met. Therefore, we decided that the Plan 
has to pre-approve additional hours for home health aide services.  
 
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: 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 enrollee will require an LTACH level 
of care and is currently stable for discharge. The Plan denied your request. The Plan says the requested service 
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 the enrollee is unstable for transfer without clear signs of ability to wean at this 
time. There are no services at the LTACH that the enrollee requires that are not already available and covered 
at the current facility. Transfer to the LTACH would not be clinically advantageous at this time and completion 
of treatment at the current facility is recommended.   
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, carboplatin, pemetrexed, diphenhydramine 
and Dexamethasone. 
 
You asked the Plan to pre-approve the drugs. You say that you have been getting the treatment for 36 months 
and it has helped you with your cancer treatment. The Plan denied your request. The Plan says Keytruda, 
carboplatin, pemetrexed, diphenhydramine and Dexamethasone are 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 the drugs. Our reviewer says that 
Keytruda, carboplatin, pemetrexed, diphenhydramine and Dexamethasone are not medically necessary. Our 
physician reviewer found that the requested use of Keytruda, carboplatin, pemetrexed, diphenhydramine and 
Dexamethasone is not FDA-approved. The requested drugs are also not supported by one of the major drug 
compendia or by clinical research. 
 
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 Keytruda, carboplatin, pemetrexed, diphenhydramine and Dexamethasone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. We are not told of low blood sugars and the medications that the 
enrollee is on do not usually cause low blood sugars. Although a CGM may help the enrollee, the criteria for 
coverage are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the PET scan and radiation therapy provided 
on April 5, 2023. 
 
You asked the Plan to waive the cost share for the PET scan and radiation therapy. You say that you do not 
agree with the cost share amount you have been billed. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for therapeutic radiology services and a $100 copayment for CTA, MRA, PET, SPECT, other 
nuclear medicine tests provided at a freestanding facility/office. 
 
You have been asked to pay a total of $202.20 for the PET scan and radiation therapy.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
April 5, 2023 Radiation Therapy $511 20% $102.20 
April 5, 2023 PET scan $1,511 $100 $100 
TOTAL:    $202.20 
 
These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 cost share for the PET scan and radiation therapy provided on 
April 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is necessary for 
you to receive care from a wound care specialist. The Plan denied your request. The Plan says you do not meet 
Medicare guidelines for care in an LTACH. 
 
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. Our physician reviewer 
found you are receiving appropriate care in the current acute care setting as provided by the Plan. The 
documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polio and diphtheria (TDaP) vaccinations received on 
September 28, 2022. 
 
You asked the Plan to pay for the vaccinations. You say that you thought these vaccinations were covered. The 
Plan denied your request. The Plan says these immunizations are not covered under your Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccinations. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccinations. 
Therefore, we decided that the Plan does not have to pay for polio and diphtheria (TDaP) vaccinations received 
on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F1CDx testing provided on April 26, 2023. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that F1CDx testing is only covered for certain indications. 
 
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 F1CDx testing. Our reviewer says that 
the documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of esophageal cancer. The medical records indicate that 
the enrollee had an esophagus biopsy on April 3, 2023, that showed squamous cell cancer. The Oncologist's 
note from April 4, 2023, states that the enrollee has "an earlier-stage esophageal carcinoma". The 
documentation shows that the enrollee did not meet the coverage criteria. 
 
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 F1CDx testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the F1CDx testing provided on April 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
May 23, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on May 23, 2023.
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 enrollee exceeds the CMS 
established defining criteria for an appropriate Long Term Acute Care Hospital admission. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable 
for transfer to an LTACH.  
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio bracelet (K1018). 
 
You asked the Plan to pre-approve a Cala Trio bracelet. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Cala Trio bracelet have been met. No medical records were submitted. Therefore, we decided that the Plan does not have to pre-approve a Cala Trio 
bracelet (K1018).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone (G2078) provided on 
March 20, 2023, by an OON provider.  You asked the Plan to pay for the take home supply of methadone (G2078). You say that you are appealing the 
denial with supporting documentation. The Plan denied your request. The Plan says the service 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 the take home supply of methadone (G2078) 
provided on March 20, 2023, by an OON provider.