Persius/hicric huggingface dataset:
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 Intracept procedure. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental/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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 86-year-old male was being treated for spondylosis without myelopathy or 
radiculopathy. He presented with chronic and worsening low back pain. The pain does not radiate. The exam 
reveals a slow and cautious gait, that is slightly antalgic. There is tenderness to deep palpation over the lumbar 
facet columns at L4, 5, and S1. Facet loading is positive bilaterally. 
 
However, the magnetic resonance imaging (MRI) scan dated May 11, 2022, did not demonstrate any Modic 
changes at the L4-5 level. In this case, there were/are multiple plausible pathologic sources of significant pain 
generation. Overall, 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.There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the request for Intracept intraosseous nerve ablation at L4-5 and L5-S1 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage II squamous cell 
carcinoma of the bladder and underwent transurethral resection. Keytruda is being requested for use as 
adjuvant first line monotherapy post-procedure. The Food and Drug Administration (FDA) has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Keytruda is 
not reasonable or medically necessary or safe and effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
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 additional routine transportation trips.
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. The Plan denied your request. The Plan says the 
enrollee is currently unstable for transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with blastic plasmacytoid dendritic 
neoplasm. He was treated with chemotherapy but was complicated by acute cholecystitis, acute respiratory 
failure, pneumonia, bacteremia, pleural effusion. He appears to be somewhat unstable and requires short-term 
additional acute care services that can be safely completed at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as he is not yet stable, and 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intravenous Immune Globulin (IVIg) Privigen. 
 
You asked the Plan to pre-approve Privigen. You say that the enrollee has thrombocytopenia. The Plan denied 
your request. The Plan says the use is not supported 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 Privigen. Our physician reviewer found 
that the record indicates the enrollee has a diagnosis of red cell aplasia and pancytopenia in the setting of 
chemotherapy. The 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 noted diagnosis is not one for which coverage is available under the local 
coverage determination. 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 Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Intravenous Immune Globulin (IVIg) Privigen.
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 service is medically necessary. The 
Plan denied your request. The Plan says the service 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 there are no services at the LTACH that the patient requires that are not already 
available and covered 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. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care 
hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the thorax to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve CT scan services. You say that these medical services are reasonable and 
necessary. The Plan denied your request. The Plan says there are in-network providers available to provide the 
care you need. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the computed tomography (CT) scan of the thorax to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria to be used with Doxorubicin, 
Cyclophosphamide, and Paclitaxel. 
 
You asked the Plan to pre-approve Nyvepria. The Plan denied your request. The Plan says the enrollee has not 
tried and failed two of Neulasta, Fulphila, or Udenyca. 
 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 Nyvepria. Our physician reviewer 
found that Nyvepria was requested to treat chemotherapy related neutropenia/febrile neutropenia. The Plan 
requires a trial of two of Neulasta, Fulphila, or Udenyca before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the Plans required drugs would likely be less effective 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 Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria to be used with Doxorubicin, Cyclophosphamide, and Paclitaxel.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D imaging with post-processing. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has elevated prostate 
specific antigen (PSA) and lower urinary tract symptoms. Magnetic resonance imaging (MRI) has been 
approved but not yet performed. The records do not support that the requested 3D imaging with post-
processing is reasonable and medically necessary for the planned MRI. 
 
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 3D imaging with post-processing.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eligard (J9217). 
 
You asked the Plan to pre-approve Eligard. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says that the criteria for coverage have not been met as this drug is not covered under the 
medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
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.  
 
In this case, the Plan originally denied coverage for the requested rug as not being covered under the medical 
benefit. However, upon further research the Plan confirmed that the requested drug is being supplied from the 
physicians supply and billed under the buy-and-bill process. Therefore, this drug would be considered eligible 
for coverage under Medicare Part B. 
 
Therefore, 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 Eligard. Our reviewer says that 
the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is an 82-
year-old diagnosed with prostate cancer in 2018. In this case, the requested use of Eligard is FDA-approved for 
the enrollees diagnosis. The requested drug is medically 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 Eligard have been met. Therefore, we decided that the Plan has to pre-approve 
Eligard (J9217).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone density DEXA scan provided on October 12, 2021. 
 
You asked the Plan to pay for a bone density DEXA scan. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the Plan has not received the medical records to determine if the 
services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 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 bone density DEXA scan provided 
on October 12, 2021 have been met. The file is missing the medical records to determine if Medicare coverage 
criteria have been met. Therefore, we decided that the Plan does not have to pay for a bone density DEXA scan 
provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
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 lab 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 lab services provided on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on August 5, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation coded 99253 provided on 
September 20, 2021. 
 
You asked the Plan to pay for the inpatient consultation. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99253 is inpatient consultation for a new or established 
patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical 
decision making of low complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 
 We find that CPT code 99253 is not supported in the medical record. Specifically, this code has a status code of 
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to 
pay for the inpatient consultation coded 99253 provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. Records show that you received a previous injection on April 25, 
2022. A repeat injection is covered when there is at least 50% sustained pain relief for at least three months. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve epidural steroid injections.