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

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that you would like to request 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the criteria for approval 
have not been met. 
 
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 parathyroid planar imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is not thought to be a surgical candidate. Unless this evaluation 
has changed after seeing a parathyroid surgeon, there is no indication to localize the parathyroid adenoma if no 
surgery is planned. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parathyroid planar imaging (78070).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve RFA. 
 
You asked the Plan to pre-approve a genicular nerve RFA. You say that you are not a candidate for a knee 
replacement and your provider recommended the requested procedure for pain. The Plan denied your request. 
The Plan says the requested procedure does not meet the criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the procedure is considered experimental and 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 a genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve RFA.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the administration. We decided that the Plan does 
not have to waive the cost sharing for the injection.  
 You asked the Plan to waive the cost sharing for the denosumab injection, and the administration provided by 
an in-network provider on May 8, 2023. You say that you think that the cost sharing is too high. The Plan says 
that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost sharing for the administration.  
 
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 says that you pay no additional cost for 
the administration of Part B drugs. The Plan says you must pay a $69.12 deductible for the administration. 
Based on the Plan contract, however, you cannot be asked to pay any cost sharing for the administration of Part 
B drugs. Therefore, we decided that the Plan has to waive the cost sharing for the administration.  
 
We also decided that the Plan does not have to waive the cost sharing for the injection. 
 
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 in-network Medicare Part B covered drugs provided in all places of service.  
 
You have been asked to pay a $283.12 coinsurance for the injection ($1,415.61 allowed amount x .20 = 
$283.12). This item/service falls within the Medicare Part B prescription drugs benefit category. 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 sharing for the injection. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections. 
 
You asked the Plan to pre-approve Botox injections. You say that the requested drug is required to treat the 
enrollee's temporomandibular joint disorder (TMD). The Plan denied your request. The Plan says the use of the 
requested drug is not supported for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox injection. Our reviewer says that 
the requested drug does not meet the necessary criteria for approval. Our physician reviewer found Botox is an 
off-label drug and the requested use is not supported by one of the major drug compendia or by clinical 
research. The drug, Dysport, does however have supporting literature in oromandibular dystonia, but Botox 
does not. Therefore, the requested drug is not medically reasonable and necessary for use 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 Botox injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox injections.
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 you meet the criteria for services in an 
LTACH and will benefit from these services that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says admission to an LTACH 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 that you are not safe for transfer at this time as you require high levels of 
supplemental oxygen, have a chest tube on suction, do not yet have permanent enteric access, and progress 
notes suggest you are still requiring pressors. 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: 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 the denial of the requested LTACH 
services is not in the enrollee's best interest. The Plan denied your request. The Plan says admission to an 
LTACH 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 that the enrollee appears to be improving with current treatment but requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. 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 is not medically necessary as it would not 
be clinically advantageous.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the requested drug is required to treat the enrollee's 
adenocarcinoma of the lung. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for the requested drug to be approved. 
 
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 Fulphila. Our reviewer says that in this 
case, the requested drug is medically reasonable and necessary. Our physician reviewer found the requested 
drug, Fulphila, is FDA-approved for the enrollee's diagnosis. Given the previous regimen and the enrollees 
age, the risk of neutropenic fever is greater than 20%, for which Fulphilia would be recommended per the 
NCCN Guidelines. Therefore, documentation supports that the requested drug is safe and effective, and 
otherwise 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 Fulphila have been met. Therefore, we decided that the Plan has to pre-approve 
Fulphila.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 skilled nursing visits. 
 You asked the Plan to pre-approve the skilled nursing visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing visits. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to have stable vital signs and their blood sugar levels are within normal parameters. The enrollee has 
been educated regarding their diabetes mellitus. The enrollee has not been recently hospitalized and has no 
wound care needs. The enrollee requires assistance with daily activities and is receiving routine foot care. 
However, this does not require skilled nursing 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 the skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 skilled nursing visits.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at 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 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: 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 cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 patient is a 79-year-old female who was admitted to the acute care hospital with 
stroke and acute respiratory failure requiring thrombectomy, intubation, and vent support as well as tube feeds. 
Trach and feeding tubes were placed. Recent notes describe the patient as alert and following simple commands and now tolerating trach collar trials and tolerating tube feeds but requiring additional weaning.  
 
The patient appears to be improving with current treatment and should only require short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer to a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for an adult prophylaxis (D1110), bitewing x-rays 
(D0274), and periodic oral examinations (D0120) provided from January 19, 2021, to June 22, 2021. 
 
You asked the Plan to reimburse for an adult prophylaxis (D1110), bitewing x-rays (D0274), and periodic oral 
examinations (D0120). You say that you have never received a booklet or any paperwork detailing how to 
submit dental claims for reimbursement or how long you have to file. The Plan denied your request. The Plan 
says you must submit your claim to the Plan within 12 months for medical services or items. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for an adult prophylaxis (D1110), bitewing x-rays (D0274), and periodic oral 
examinations (D0120) was not filed until June 26, 2023. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to 
reimburse for an adult prophylaxis (D1110), bitewing x-rays (D0274), and periodic oral examinations (D0120) 
provided from January 19, 2021, to June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periapical x-rays (D0220/D0230) and bitewings (D0274) provided on 
June 21, 2023. 
 
You asked the Plan to pay for D0220, D0230, and D2740. You say that you told the dentist to only do services 
that were covered. The Plan denied your request. The Plan says that the denied dental services have been 
exhausted. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Evidence was not provided to show that D0220, D0230, and D0274 were 
completely exhausted prior to June 21, 2023. Therefore, we decided that the Plan has to pay for periapical x-
rays (D0220/D0230) and bitewings (D0274) provided on June 21, 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: 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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the criteria for coverage of a SNF admission have not been met. 
 
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. The enrollee 
received physical therapy and occupational at a non-skilled level. The enrollee was at total to maximum assist 
level with functional mobility. The enrollee required varying assist with activities of daily living (ADLs). There 
are no identifiable skilled nursing or skilled therapy needs. The enrollee does not meet the severity of illness or 
intensity of service criteria for an inpatient basis in a 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an additional 167 miles. 
 
You asked the Plan to pre-approve transportation.. The Plan denied your request. The Plan says you will have 
exceeded your benefit mileage 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 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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  an additional 167 miles.