Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that the enrollee is unable to get out of bed when 
the pain is aggravated. You say that the enrollee's pain returned after their first injection after a few weeks. You 
also say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says a repeat 
TFESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat TFESI. Our reviewer says that 
a repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had at least 50% pain relief for three months. Therefore, the reviewer found that a 
repeat TFESI is 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 repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation and set-up of portable x-ray equipment and 
a chest x-ray provided on September 12, 2022, by an OON provider. 
 
You asked the Plan to pay for the transportation and set-up of portable x-ray equipment and a chest x-ray. You 
say that authorization was not obtained as there was no time to obtain it. The Plan denied your request. The 
Plan says the enrollee must receive care from a network provider. 
 
 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 transportation and set-up of portable x-ray 
equipment and a chest x-ray provided on September 12, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure provided on November 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a molecular pathology procedure. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
 
 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 a molecular pathology procedure provided on 
November 17, 2021, by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee does not 
display a need for the rehabilitation services of inpatient skilled nursing facility level of care. 
 
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. 
 
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: 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 needs LTACH care. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for LTACH care. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care soon. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical 
navigational orthopedic procedure (0055T), provided on April 21, 2022. 
 
You asked the Plan to pre-approve a computer-assisted musculoskeletal surgical navigational orthopedic 
procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says in 
the absence of clinical information, medical necessity and coverage cannot be determined. With the 
information we have, we cannot determine how the member came to the servicing provider, or whether the 
services are medically necessary. 
 
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 computer-assisted musculoskeletal 
surgical navigational orthopedic procedure have been met. The documentation submitted is insufficient to 
determine medical necessity. Therefore, we decided that the Plan does not have to pre-approve a computer-
assisted musculoskeletal surgical navigational orthopedic procedure (0055T), provided on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure improves quality of life. 
The Plan denied your request. The Plan says the records do not show the enrollee's pain is only attributed to 
vertebrogenic pain. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its efficacy. 
 
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 an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous ketamine. 
 
You asked the Plan to pre-approve the services. You say that this is needed for depressive symptoms. The Plan 
denied your request. The Plan says the enrollee is deemed not to be an appropriate candidate for ketamine. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a diagnosis of  dysthymic disorder and personality. The record does 
not indicate that the enrollee has treatment-resistent depression after 2 prior conventional antidepressants. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intravenous ketamine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says PBRT 
is not the standard of care for prostate cancer. 
 
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 requested services. Our physician 
reviewer found that whether proton therapy affords a benefit over other standard approaches, such as intensity 
modulated or image guided radiation therapy (IMRT/IGRT), for prostate cancer is an area of investigation and 
remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer 
proton beam therapy on clinical trials, and to not routinely offer it to patients. Therefore, the requested service 
is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high level (CPT 99285) provided on August 28, 2022. 
 
You asked the Plan to pay for the emergency department visit (CPT 99285). You say that the correct CPT code 
was billed. The Plan denied your request. The Plan says CPT 99285 was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
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 emergency department visit (CPT 99285). Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the documentation indicates there was moderate decision making 
without a medical presentation that indicated high severity or immediate significant threat to life of 
physiological function. In this case, the documentation doesnt support the CPT 99285. 
 
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 emergency department visit (CPT 99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high level (Current Procedural Terminology (CPT) 99285) 
provided on August 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the drug is not 
approved for the enrollee's condition. 
 
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 Reblozyl. Our physician reviewer found 
that the enrollee has anemia in stage IV chronic kidney disease (CKD). The requested use of Reblozyl is not 
FDA approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not 
indicated, not supported, or not recommended in any of the compendia. The documentation does not support 
that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thigh skin excision. 
 
You asked the Plan to pre-approve thigh skin excision. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 thigh skin excision. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record indicates that the enrollee has had significant weight loss and has redundant 
skin. The primary source medical records provided do not indicate the presence of intertrigo refractory to 
treatment or functional limitations. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thigh skin excision have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thigh skin excision.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (64483). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has present of radicular pain and this is 
not a repeat injection. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show the enrollee responded well to the ESI within the first two weeks with 75% reduction 
in your pain, and 3 months have not yet elapsed to determine whether he had sustained improvement in pain 
and function. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found underwent a series of 2 bilateral transforaminal lumbar epidural steroid injections at the L5 
level in December 2022 and during follow up on January 9, 2023, reported 75% pain reduction after 2 weeks. 
His provider has recommended another L5 transforaminal epidural steroid injection.  the enrollee responded 
well to the epidural steroid injection within the first two weeks with 75% reduction in your pain, and 3 months 
have not yet elapsed to determine whether the enrollee had a sustained improvement in pain and function. The 
review has determined that the requested injections are not medically necessary for the enrollee. The enrollee 
does not meet LCD criteria for approval of the injections. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(64483).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a drug test comprising 15 to 21 drug classes (G0482) billed for date of 
service August 29, 2022. 
 
You asked the Plan to pay for drug testing. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because fewer 
than 15 drug classes were tested. 
 
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 G0482 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug 
testing have been met. Therefore, we decided that the Plan has to pay for a drug test comprising 15 to 21 drug 
classes (G0482) billed for date of service August 29, 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.