Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve an acute inpatient psychiatric hospitalization. You say that this inpatient 
admission is medically necessary. The Plan denied your request. The Plan says the enrollee was deemed okay 
for discharge on March 23, 2023. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an acute inpatient psychiatric 
hospitalization. Our reviewer says that an inpatient admission is not medically necessary. Our physician 
reviewer found Based upon review the records provided for the admission of this patient does not meet the 
criteria for March 23, 2023, forward as this enrollee was not shown to be a danger to herself or others, 
delusions, auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not 
showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospitalization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (S9122). 
 
You asked the Plan to pre-approve a home health aide. You say that you need the services and do not want to 
use the agency for your physical therapy. The Plan denied your request. The Plan says the requested services 
do not require skilled medical or nursing care and would be considered custodial. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home health aide have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home 
health aide (S9122).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on September 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152 (1 Units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; therefore, the billed service cannot be verified. Of note, an independent 
trained observer is someone other than the physician performing the services. The review has determined that 
the use of CPT 99152 is not supported by the records provided.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography studies (51785) provided on July 19, 
2022. 
 
You asked the Plan to pay for the needle electromyography studies. You say that you would like the Plan's 
denial to be overturned. The Plan denied your request. The Plan says that this service does not meet the 
coverage requirements. 
 
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. Specifically, the Plan did not specify which criteria for coverage were not met 
nor did they provide evidence that the service in dispute was performed in connection with a denied procedure. 
The Plan has not substantiated their denial reason. It is the burden of the Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated. Therefore, we decided that the Plan has to pay for 
the needle electromyography studies (51785) provided on July 19, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that the enrollee is currently on Zetia and has been on 
Repatha. You say that the enrollee has tried and failed atorvastatin, pravastatin, rosuvastatin which all caused 
myalgias. You also say that the enrollee's LDL value prior to Repatha was 178. The Plan denied your request. 
The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Leqvio. Our reviewer says that the 
requested drug, Leqvio, is not medically necessary. Our physician reviewer found the provided medical records 
do not document failure or intolerance to the Repatha the enrollee is already on. The reviewer found that the 
Medicare-approved major drug compendia indicate the Repatha appears to be a more potent agent with regard 
to low-density lipoprotein (LDL) lowering than Leqvio. The reviewer found that rational to switch the enrollee 
from Repatha to Leqvio has not been provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that there is documentation 
of trial and failure of Fosamax, but there is no indication that the enrollee has tried and failed zoledronic acid. 
Based on the medical records provided and the Medicare-approved major drug compendia there is no 
indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records do not show that the enrollee meets the above 
Medicare rules. The Plan states the enrollee has severe foraminal spinal stenosis and facet arthrosis (confirmed 
on physical exam and history of success with facet procedures), with history of radiculopathy and nature of 
pain consistent with such. 
 
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 physician 
reviewer found the documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain.  Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. Therefore, the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for CancerTYPE ID testing (81450) provided on November 2, 2022. 
 
You asked the Plan to pay for CancerTYPE ID testing. You say that this test was medically necessary and 
appropriate for the enrollee's condition. The Plan denied your request. The Plan says that tests billed with code 
81450 are automatically denied as not medically necessary. 
 
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. Medicare rules also say that molecular diagnostic laboratory tests are subject to the MolDX 
application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate 
and a unique test identifier. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the rule the Plan cited for denial in this case does not have 
jurisdiction over the state where these services were performed. In addition, the test at issue is listed in the 
DEX database as covered. This determination was made and is specific to the test at issue. Therefore, we 
decided that the Plan has to pay for CancerTYPE ID testing (81450) provided on November 2, 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 pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block for left knee is experimental. 
 
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 block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 57-year-old female with a history of left knee pain x3 years. A 
magnetic resonance imaging (MRI) of the knee demonstrates mild interval worsening of tri-compartmental 
chondrosis, unchanged free edge tearing of lateral meniscal body, and degenerative tearing of the anterior horn. 
The enrollee is diagnosed with chronic left knee pain due to tri-compartment osteoarthritis of left knee. The enrollee has completed medical therapy, including physical therapy and home exercise. Genicular nerve blocks 
and genicular nerve ablation are considered investigational and not medically necessary for the treatment of 
chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis 
of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a 
treatment for individuals who are not candidates for knee replacement surgery. The review has determined that 
the genicular nerve blocks are not medically reasonable or 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T). 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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 high dose rate electronic brachytherapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Mohs surgery is the most effective technique for removing SCCs, 
sparing the greatest amount of healthy tissue while achieving the highest possible cure rate - up to 97 percent 
for tumors treated for the first time. The review has determined that the items/services at issue in this case are not medically reasonable or 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 high dose rate electronic brachytherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36410 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the clinical records support this service. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36410 is venipuncture, age 3 years or older, necessitating 
the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or 
therapeutic purposes (not to be used for routine venipuncture). 
 We find that CPT code 36410 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 36410 billed for date of service August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the providers, you have been able to manage symptoms to avoid cellulitis, 
necrosis or refractory ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
requested surgery is not medically reasonable or necessary. Our reviewer found that in this case, the record 
indicates that the enrollee has localized adiposity with pannus. The record does not document the presence 
of chronic, intertriginous rash associated with the panniculus that has caused recurrent cellulitis, skin necrosis, or ulceration of the skin and that is not responsive to medical treatment. The record provided does not indicate 
that the requested procedure is for the prompt repair of accidental injury or for the improvement of the 
functioning of a malformed body member. 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve panniculectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1018 and K1019), 
provided on November 7, 2022. 
 You asked the Plan to pay for the Cala Trio nerve stimulator device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1018 and K1019), provided on 
November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic/surgical implant (D6190) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 a 
radiographic/surgical implant (D6190) provided on November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
microcytic anemia secondary chronic inflammation in the setting of chronic disease. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved  drug compendia do not contain a supportive citation for the use of the requested drug in 
the enrollee's clinical situation. The services are therefore 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 Aranesp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are exclusionary radiographic findings, such as lumbar spondylosis and facet 
arthrosis. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the imaging studies show spondylolisthesis and facet degenerative joint disease (DJD). The 
cause of the back pain is unclear. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.