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

 
We decided that the Plan does not have to pre-approve facet injection lumbosacral 1 level (64493 and 64494). 
 
You asked the Plan to pre-approve facet injections. You say that you disagree with the denial and have 
submitted clinical documentation. The Plan denied your request. The Plan says the medical records submitted 
does not establish that the requested injections are reasonable and necessary because the enrollee is not 
compliant with physical therapy or a home exercise program. 
 
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 facet injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that according to the coverage criteria, an initial diagnostic facet joint procedure will be 
considered medically reasonable and necessary when the enrollee meets the criteria outlined under the 
indications for facet joint interventions. A second confirmatory diagnostic facet joint procedure is considered 
medically reasonable and necessary in enrollee who meet both of the following criteria, the enrollee meets the 
criteria for the first diagnostic procedure; and after the first diagnostic facet joint procedure, there must be a 
consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). In this case, the first MBBs provided only 50% relief of pain. The review 
has determined that the enrollee does not meet the coverage criteria for the requested injections. The injections 
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 facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injection lumbosacral 1 level (64493 and 64494).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended sleep study (95800). 
 
You asked the Plan to pre-approve an unattended sleep study. The Plan denied your request. The Plan says this 
request cannot be approved because a test similar to the one requested has already been approved for the 
enrollee in October, 2022. The Plan also says results of the prior approved study or test that show the need for 
repeat testing are needed, or confirmation that the prior approved testing was not, or will not be performed. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat PSG or HST for diagnosing sleep apnea 
requires documentation justifying the medical necessity for the repeated test. 
 
 
 
 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 unattended sleep study. Our 
reviewer says that based on the medical records provided there is no documentation that the sleep study 
(95800) at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. 
Our physician reviewer found the provided records in this case document a diagnosis of obstructive sleep apnea 
with a history of a continuous positive airway pressure (CPAP) titration in 2009. The enrollee is reported to be 
experiencing nightly palpitations and snoring. Our reviewer found that the records do not clarify if the enrollee 
is presently using CPAP and if so, how frequently, and if they are benefiting from it. Our physician reviewer 
also found that the provided records do not document necessity of a second sleep study as a sleep study was 
already approved in October 2022. 
 
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 unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an unattended sleep study (95800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 4, 2023, billed with 
code 94664. 
 
You asked the Plan to pay for the services as billed. You say that the records support payment for both codes.  
The Plan denied your request. The Plan says the code 94664 cannot be paid in the facility setting.  
 
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 find that CPT code 94664 has a Professional Component/Technical Component (PC/TC) indicator of 5. 
This indicator identifies codes that describe services covered incident to a physician's service when they are 
provided by auxiliary personnel employed by the physician and working under his or her direct personal 
supervision. Payment may not be made for these services when they are provided to hospital inpatients or 
patients in a hospital outpatient department. The file shows this service was provided to a hospital outpatient. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 4, 
2023, billed with code 94664.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3-dimensional (3D) rendering (76376). 
 
You asked the Plan to pre-approve a 3D rendering. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that three-dimensional imaging is medically reasonable 
and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. 
 
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 3D rendering. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there apparently is a request for 3D 
rendering for magnetic resonance cholangio pancreatography (MRCP), but there is no discussion concerning 
the need for the MRCP. If a MRCP ends up being approved the 3D rendering is necessary for proper 
interpretation of that study, but there are no notes present discussing the need. 
 
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 3D rendering have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a 3-dimensional (3D) rendering (76376).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have very limited mobility, strength, and 
diabetes so IRF care would provide you with the best opportunity to regain your prior quality of life. The Plan 
denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability 
and failure of such a device has not been documented. The Plan has indicated coverage for such a device is 
available upon request. The elements of the coverage criteria are not satisfied. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87507 for date of service 
January 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were provided in good faith. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 87507 
for date of service January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. 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 the services. 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 prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
Recent data shows no significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton beam therapy and IMRT. The most recent American Urological Association (AUA) 
and National Comprehensive Cancer Network (NCCN) guidelines state that PBT offers no clinical advantage 
over other forms of definitive treatment. According to NCCN and American Society for Radiation Oncology 
(ASTRO) guidelines proton beam therapy may be offered to individuals enrolled in an Institutional Review 
Board (IRB) approved prospective clinical trial or multi-institutional registry that adheres to Medicare 
requirements for coverage with evidence development (CED). The records do not show that the enrollee is 
enrolled in a clinical trial. The records show the enrollee has been enrolled in a registry. 
 
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 the proton treatment delivery; intermediate (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99222, 99232 and 99239 billed for dates of 
service from October 20, 2022, to October 23, 2022. 
 
You asked the Plan to pay for procedure codes 99222, 99232 and 99239. You say that you have correctly billed 
the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 find that CPT codes 99222, 99232 and 99239 is not supported in the case record. Specifically, medical 
records to support the CPT codes at issue have not been provided for review. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99222, 99232 and 99239 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99222, 99232 and 99239 billed 
for dates of service from October 20, 2022, to October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Electroconvulsive Therapy (ECT). 
 
You asked the Plan to pre-approve additional ECT. 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 additional ECT. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the records provided, this enrollee has been stabilized where he did not have any 
imminent danger to self or others. He did not have any aggressive or threatening behavior to others and was not 
violent. The enrollee has been compliant with treatment. The enrollee has been cooperative according to 
documentation. Based on the information provided, this enrollee does not meet criteria for the use of ECT. 
Additional treatments are not reasonable or medically necessary as this enrollee does not meet criteria for the 
use of ECT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ECT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional Electroconvulsive Therapy (ECT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (LAAC). 
 
You asked the Plan to pre-approve LAAC. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when certain criteria are met. 
 
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 LAAC. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records in this case do not 
document a formal shared decision-making interaction with an independent non-interventional physician using 
an evidence-based decision tool on oral anticoagulation in patients with non-valvular atrial fibrillation (NVAF) 
prior to LAAC. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Left Atrial Appendage Closure (LAAC).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron (J2469). 
 
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says the requested use 
in this case is not found to be reasonable and necessary per review of compendia. 
 
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 Palonosetron. Our reviewer says that 
Palonosetron is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Palonosetron is not FDA-approved for the enrollees diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS) approved medical journal. Our reviewer also found that the use is not listed as not indicated, 
not supported or not recommended in any of the compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron (J2469).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on October 26, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the OON podiatry services. You say that the enrollee did not provide their 
insurance card at the time of the service. You say that the enrollee provided their Medicare card. You say that 
the doctor provided these services in good faith and should not be penalized.  The Plan denied your request. 
The Plan says the services provided were not authorized.  
 
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 podiatry services provided on October 26, 2022, 
by an out-of-network (OON) provider.