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

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental and non-covered. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation services. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says the requested services are 
considered investigational. 
 
 
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 genicular nerve radiofrequency ablation 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you are a 48-year-old female with chronic knee pain, 
knee osteoarthritis, and have failed uni-compartmental arthroplasties. Your provider is requesting coverage for 
a genicular nerve radiofrequency ablation. 
 
Genicular nerve blocks and genicular nerve radiofrequency 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 requested genicular nerve ablations are considered 
experimental/investigational in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are working with 
speech, physical and occupational therapy services and are making progress in the acute inpatient rehabilitation 
facility. You do not require the services on an inpatient basis, only in a skilled nursing facility setting.  
Continued care in the acute inpatient rehabilitation facility is appropriate until you are stable to transfer to 
home with home health care or to an alternative long term care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue expander placement in breast reconstruction, including 
subsequent expansion(s) (CPT code 19357 LT&RT X 2) provided on August 23, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 19357-RT and 19357-LT,59 exceed the allowable UOS of 1 for the same date of service. Per the 
MAI indicator of 2, 19357-RT and 19357-LT,59 were not billed correctly per the bilateral surgery indicator 
of 1. We find that Medicare rule for payment of this claim has not been met. If the provider determines that a 
billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a 
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for 
tissue expander placement in breast reconstruction, including subsequent expansion(s) (CPT code 19357 
LT&RT X 2) provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 82656) provided on 
February 11, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 82656) provided 
on February 11, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for metabolic encephalopathy, 
pneumonia, COVID 19, and respiratory failure. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says Xiidra is a self-
administered drug. The Plan also says that this medication does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased on December 26, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you were told that you could use an out-of-
network provider and get a benefit of 50% of the allowd amount. The Plan denied your request. The Plan says 
there are no out-of-network benefits for hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received from the Plan's designated hearing aid vendor.  This is explicitly stated in your 
Evidence of Coverage. You did not use the Plan's designated vendor for the hearing aids in question. Based on 
this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, 
we decided that the Plan does not have to pay for hearing aids you purchased on December 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 3, 2021, through 
March 5, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the provider submitted supporting 
documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says the 
determination to remove secondary diagnosis code assignment of J96.01 acute respiratory failure with hypoxia 
is upheld. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 inpatient hospital care. Our physician 
reviewer found the review has determined that diagnosis code J96.01- acute respiratory failure with hypoxia 
was not supported by the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided from March 3, 2021, through March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81219 and 81339) 
provided on December 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The member had molecular pathology testing on December 20, 2021. The denial remains upheld as non-
covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to 
pay for molecular pathology testing (CPT code(s): 81219 and 81339) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit (99203) you had on March 1, 
2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit (99203) you had on March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83631, 83520, 82656, 
87338, and 82274) provided on January 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code(s): 83631, 83520, 82656, 87338, and 
82274) provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 17, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no 
benefit for a cardiovascular screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was not ordered for a specific medical problem. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on August 17, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve Guardant testing (81479). 
 
You asked the Plan to pre-approve Guardant testing. You say that the enrollee needs Guardant testing for 
complete genomic profile to drive treatment options. The Plan denied your request. The Plan says that there is 
not good medical evidence that shows doing the large number of tests in a Guardant360 Profile is helpful with 
management of the type of cancer that the enrollee has. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant360 remains covered if the tissue-based 
comprehensive genomic profiling (CGP) is infeasible. 
 
 
  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 Guardant testing. Our reviewer says 
that the service is reasonable and medically necessary. Our physician reviewer found the National 
Comprehensive Cancer Network (NCCN) Guidelines for pancreatic cancer recommend tumor molecular 
profiling for all patients with metastatic cancer who are candidates for anti-cancer therapy to identify 
uncommon mutations. Our reviewer found that although testing on tumor tissue is preferred, liquid testing can 
be considered if tumor tissue testing is not feasible. Our physician reviewer also found that there is insufficient 
tissue for this patient and that is why liquid biopsy with Guardant was sent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Guardant testing have been met. Therefore, we decided that the Plan has to pre-
approve Guardant testing (81479).  
 
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 continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is 
walking household distances with a rolling walker with contact guard assistance with touch down weight 
bearing and is contact guard assist for transfers. Provided records do not document a significant decline in the 
enrollees functional status to necessitate further daily inpatient skilled therapy services. The enrollee does not 
require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the home with home health care or in a long-term care facility on a part time basis are not 
appropriate 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Stelara. 
 
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 Entyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Stelara. The reviewer found that the documentation 
does not support that Stelara would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).