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

 
We decided that the Plan does not have to pre-approve genicular nerve block injections. 
 
You asked the Plan to pre-approve genicular nerve block injections. You say that this is medically necessary. 
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 genicular nerve block injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental/ investigational. It is the subject 
of ongoing clinical trials. Therefore, the request is deemed not 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 genicular nerve block injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic, prophylactic, or diagnostic injection (96372) 
provided on April 10, 2023. 
 
 You asked the Plan to pay for a therapeutic, prophylactic, or diagnostic injection. You say that code 96372 is 
covered by the CMS fee schedule and was medically necessary for the enrollee. The Plan denied your request. 
The Plan says procedure code 96372 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Specifically, code 96372 is listed as a STV-packaged service, which 
has a status indicator of Q1. The documentation shows that this claim was also billed with CPT code 99284 
which has a status indicator of V. The payment for 96372 is packaged into the payment for the services with 
status indicator V and no separate payment is made. Based on this information, we decided that Medicare rules 
for coverage of a therapeutic, prophylactic, or diagnostic injection have not been met. Therefore, we decided 
that the Plan does not have to pay for a therapeutic, prophylactic, or diagnostic injection (96372) provided on 
April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Identiti Nanotec cervical implant (22853). 
 
You asked the Plan to pre-approve the implant. You say that you need this surgery. You say that your arm does 
not work and there is a risk of paralysis if this does not work. You say that you have had to wait two years. You 
also say that you are not sleeping as you are in so much pain. The Plan denied your request. The Plan says the 
clinical value and effectiveness of the Identiti Nanotec cervical implant have not been demonstrated in the 
peer-reviewed literature. 
 
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 implant. Our reviewer says that the 
requested Identiti Nanotec implant is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding the surgical plan including the use of auto and/or allograft composed of cancellous and/or cortico-cancellous bone graft and implanted via an open, 
anterior approach/corpectomy. The Food and Drug Administration (FDA) approval indicates this device is 
typically to be utilized in this fashion. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the reviewer found that the requested Identiti Nanotec cervical implant 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 implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Identiti Nanotec cervical implant (22853).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs SNF care. The Plan 
denied your request. The Plan says these services can be provided in-network. 
 
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 skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0003). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item has been requested for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an irreversible electroporation ablation (Nanoknife) 
procedure (0601T, 0600T). 
 
You asked the Plan to pre-approve a Nanoknife procedure. 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 a Nanoknife procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient published scientific evidence to support Nanoknife as medically 
necessary in this clinical scenario, and documentation does not support that criteria outlined are 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 a Nanoknife procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an irreversible electroporation ablation (Nanoknife) procedure (0601T, 0600T).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the brain to be rendered by an OON provider. We 
decided that the Plan does not have to pre-approve an MRI of the brain to be provided at the in-network cost 
share amount.  
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) of the brain (70553) to be provided by 
an out-of-network (OON) provider. You say that the enrollee reported continuing and worsening headaches 
that have now failed to respond to all typical conservative treatment. You also say that given the persistence of 
pain, corroborating exam findings, and failure to respond to all conservative measures over the last few months, 
you are recommending a brain MRI with and without contrast. The Plan says that the facility chosen is not in-
network with the enrollee's health plan. The Plan also says there are two in-network providers within 10 miles 
of the enrollee's home address who could perform the requested service. 
 
We decided that the Plan has to pre-approve an MRI of the brain to be rendered by an OON provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract says the 
Plan will cover services from either network or out-of-network providers, as long as the services are covered 
benefits and are medically necessary. If you use an out-of-network provider, your share of the costs for your 
covered services may be higher. 
 
Although the Plan has denied this service based on it being available from in-network providers, the Plan 
contract states that services are covered both in and out-of-network. Therefore, we decided that the Plan has to 
pre-approve an MRI of the brain to be rendered by an OON provider.  
 
We also decided that the Plan does not have to pre-approve an MRI of the brain to be provided at the in-
network cost share amount. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract says the 
Plan will cover services from either network or out-of-network providers, as long as the services are covered 
benefits and are medically necessary. If you use an out-of-network provider, your share of the costs for your 
covered services may be higher. 
 
Though the enrollees plan does offer coverage for services rendered by OON providers, the enrollee is 
responsible for 35% coinsurance for outpatient diagnostic tests and therapeutic services and supplies when the 
service is rendered by an OON provider. Therefore, we decided that the Plan does not have to pre-approve an 
MRI of the brain to be provided at the in-network cost share amount. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have been going to kidney 
dialysis for three years, and desperately need to stay up to date with your kidney treatments. The Plan denied 
your request. The Plan says this request exceeds the maximum count allowed per period. 
 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 up to 60 one-way 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 transportation.
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 this care. The Plan 
denied your request. The Plan says the enrollee's care can be safely managed in the current acute setting until 
they are medically stable 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH 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. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
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 criteria have not 
been met and your provider has not demonstrated that it is medically necessary to make an exception for you. 
 
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 the 
enrollee does not meet the coverage criteria for Prolia. Our physician reviewer found the provided records do 
not document that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 14, 2022, 
to June 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
would like to be reimbursed pursuant to DRG 193 for services rendered. The Plan denied your request. The 
Plan says the review did not find sufficient documentation to clinically validate the diagnosis of J15.9, 
Unspecified bacterial pneumonia. 
 
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.   
 
In this case, you billed the inpatient services provided with primary diagnosis code, J15.9, defined as 
Unspecified bacterial pneumonia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the criteria for pneumonia were not present.  
 
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 the inpatient hospital services provided from June 14, 2022, to June 23, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genicular Artery Embolization (GAE) (36247, 36246, 
36245). 
 
You asked the Plan to pre-approve GAE. You say that this procedure is medically necessary. The Plan denied 
your request. The Plan says this procedure is considered experimental and 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 GAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be 
promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
genicular artery embolization 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 GAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Genicular Artery Embolization (GAE) (36247, 36246, 36245).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta injections. You say that the medical records submitted support the 
reconsideration of the denied drug. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for the requested drug. 
 
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 Zilretta injections. Our reviewer says 
that the requested drug, Zilretta, does not meet the criteria needed for approval. Our physician reviewer found 
the requested use of Zilretta is not supported by one of the major drug compendia, by clinical research, or 
FDA-approved for the enrollee's diagnosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zilretta injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump billed with code E0781-NU for date of 
service January 13, 2023. 
 
You asked the Plan to pay for code E0781. You say that this item was prescribed for use after the patient's 
surgery and it was medically necessary. The Plan denied your request. The Plan says you did not bill correctly 
for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that capped rental items must be rented, and not 
purchased.  Medicare covers these items with a monthly rental fee. 
 In this case, code E0781 is designated as a capped rental item.  As a result, this item can only be rented, not 
purchased.  You billed this item with the NU modifier, indicating that this item was purchased, and not rented.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0781 have not been met. Therefore, we decided that the Plan does not have to pay for the 
infusion pump billed with code E0781-NU for date of service January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertilfex device is experimental. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ESI. 
 
You asked the Plan to pre-approve the injections. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the request 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 the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous 
epidural steroid injection. Therefore, the criteria for coverage 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ESI.