Persius/hicric huggingface dataset:
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 the IRF care. You say that the IRF admission is medically necessary. The 
Plan denied your request. The Plan says you do not meet the criteria for the IRF admission. 
 
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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF as medically necessary care 
can be provided in a different 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1-L5 kyphoplasty (22511, 22512). 
 
You asked the Plan to pre-approve L1-L5 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria are not met as the pain is multifactorial. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L1-L5 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding osteoporosis of the lumbar spine on the cone density scan from August 28, 2023. There is 
no indication of a progression of the body height loss, greater than 25% vertebral body height loss, or kyphotic 
deformity. Moreover, there is magnetic resonance imaging corroboration of retropulsion at the L1 vertebra as 
well as other plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1-L5 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve L1-L5 kyphoplasty (22511, 22512).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from March 1, 2023, 
to March 25, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that a separate appeal was ruled in your 
favor, and you believe it should waive this 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 $0 
copayment per day for days 1-20 of SNF stays for each benefit period. Your contract with the Plan also clearly says that you must pay a $196 copayment per day for days 21-100 of SNF stays for each benefit period. 
 
The records show you had received four days of SNF care from February 25, 2023, to February 28, 2023, 
which had a $0 copayment applied per day. You also received 16 days of SNF care from March 1, 2023, to 
March 16, 2023, which had a $0 copayment applied per day. You have been asked to pay a $196 copayment 
per day for the SNF stay provided from March 17, 2023, to March 25, 2023. You have been asked to pay a 
total of $1,568 ($196 copayment per day x 8 days = $1,568). You have not been charged for the day you were 
discharged. This item/service falls within the skilled nursing facility 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 the SNF stay provided from March 1, 2023, to March 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
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 enrollee does not meet evidence-based criteria. 
 
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 showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of 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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 20, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that the billing is clearly in 
error. Please void and correct. 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 $10 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 office visit provided on March 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on February 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that you have 
had this test done two years in a row and it did not matter if it was 12 months between tests or not. 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 $150 
copayment for Medicare-covered services provided in an ambulatory surgical center. 
 
You have been asked to pay a $150 copayment for an in-network diagnostic colonoscopy. This item/service falls within the Medicare-covered services provided in an ambulatory surgical center 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 an in-network diagnostic colonoscopy provided on February 
08, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, bevacizumab, Eylea, and Byooviz or Cimerli. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Lucentis is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) generator. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether implantation of the CCM system in this enrollee is medically necessary for the 
treatment of congestive heart failure, which has been deemed refractory to optimal medical therapy. While the 
clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-
term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cardiac contractility modulation (CCM) generator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 17, 2023. 
 
You asked the Plan to pay for office visit. You say that you are asking for the submitted medical records be 
reviewed. 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 office visit provided on 
April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit.  
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor kit. You say that you are not able to check 
blood glucose with test strips by yourself as it's too hard for you. You also say that the sensor is so helpful as it 
lets you know when you need to eat if you level drops, especially at nighttime.  The Plan denied your request. 
The Plan says coverage for the CGM have not been 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 FreeStyle Libre 2 sensor kit. Our 
reviewer says that the FreeStyle Libre 2 sensor kit.is not medically necessary. Our physician reviewer found 
the record indicates that you have diabetes. The record provided does not indicate that you are being treated 
with insulin or have problematic hypoglycemia as defined by the Medicare rule. The elements of 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 the FreeStyle Libre 2 sensor kit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says this drug 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 Opdivo. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of metastatic adenocarcinoma of the lung who had progression on Keytruda, a checkpoint inhibitor.  
The FDA has not stated that the requested drug is indicated for the enrollee's condition  The Medicare approved cancer drug compendia does not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo (J9299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON services. You say that Covid-19 testing should be reimbursed. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that presumptive and definitive drug testing, not Covid-19 testing, was provided. The provider 
in this case is not a network provider with the Plan. The Plan had network providers available who could have 
provided the services at issue in this appeal. 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 the lab services provided on March 20, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on November 27, 2022. 
 
You asked the Plan to pay for x-rays. You say that you say that you could not receive authorization as the 
services were performed in the emergency room. 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 x-rays provided on 
November 27, 2022.
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's life is endangered, and safety skilled 
nursing is not an option due to coming off covid with a diagnosis of recurring pneumonia. The Plan denied 
your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet 
the requirements for approval. 
 
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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 CDx testing billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the date of service should be the date of 
performance. The Plan denied your request. The Plan says that the collection date is considered the date of 
service. 
 
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. 
 
We looked at the file and the rules. The billed date of service was the date at which the testing was performed. 
The Plan has not shown that the date of service does not meet one of the exceptions. 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 the Guardant360 CDx testing billed for date of 
service January 25, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical removal of erupted tooth (D7210) for tooth 
#18 and the deep sedation (D9222 and D9223) and to pay for the biological materials (D4265) and the 
therapeutic drug (D9610) provided on January 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told that you would only have to 
pay half the amount and now you are being told you have to pay more. The Plan denied your request. The Plan 
says the proper cost share was applied for the surgical removal of erupted tooth and deep sedation. Also, the 
biological materials and the therapeutic drug 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. The total allowed amount for the surgical removal of erupted tooth (D7210) was $149 with a coinsurance 
amount of $74.50 ($149 allowed x 50% coinsurance). The total allowed amount for the deep sedation (D9222) 
was $70 with a coinsurance amount of $35 ($70 allowed x 50% coinsurance). The total allowed amount for the 
deep sedation (D9223) was $70 with a coinsurance amount of $35 ($70 allowed x 50% coinsurance). 
 
You have been asked to pay a $10 copayment for the office visit and a 50% coinsurance for the surgical 
removal of erupted tooth (D7210) and the deep sedation (D9222 and D9223). This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The biological materials and the therapeutic drug 
are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay more 
for the surgical removal of erupted tooth (D7210) for tooth #18 and the deep sedation (D9222 and D9223) and 
to pay for the biological materials (D4265) and the therapeutic drug (D9610) provided on January 20, 2023.