Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an NTX-100 Tonic Motor Activation (TOMAC) system 
(E1399). 
 
You asked the Plan to pre-approve a Tonic Motor Activation system. You say that the multiple peer reviewed 
articles demonstrate the safety and efficacy of the requested system. The Plan denied your request. The Plan 
says scientific research has not established tonic motor activation's long-term effectiveness and improvement 
on outcomes for the treatment of restless leg syndrome. 
 
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 Tonic Motor Activation system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the NTX-100 Tonic Motor Activation (TOMAC) System has been shown 
in controlled studies in a Centers for Medicare & Medicaid Services (CMS)-approved journal to result in long 
term health benefits in enrollees with restless leg syndrome. As summarized in Up to Date: "A variety of 
noninvasive neurostimulation or neuromodulation techniques are under investigation for restless leg syndrome, 
which may eventually be an option in enrollees with mild symptoms or who cannot tolerate medications." 
 
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 Tonic Motor Activation system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an NTX-100 Tonic Motor Activation (TOMAC) system (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63056 and 63057 rendered on March 16, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 63056: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far 
lateral herniated intervertebral disc) 
 
CPT 63057: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to 
code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation does not support 
that CPT 63056 or CPT 63057 were rendered in this case. The enrollee was being treated for intervertebral disc 
displacement of the lumbar region, radiculopathy of the lumbar region, and spinal stenosis of the lumbar region 
without neurogenic claudication. She underwent a discectomy, anterior lumbar, right L3-4, left L4-5, and L5-
S1 discectomy on 3/16/23. The procedure details cite the incision was made taken down to the S1 spinous 
process and lamina were identified and then the prior laminectomy defects were identified from L3-S1. The 
right L3-4 disc was identified, and the discectomy was performed in the standard fashion with additional 
lamina removed as well as foraminotomies performed at the L3-4 disc space. The left L4-5 disc was identified 
with x-ray and the discectomy was performed in the standard fashion and then the L4-5 foramina on the left 
was completed to allow greater access for the nerve root to exit. Despite the appeal note stating he approached 
the disc herniations at L4-5 and L5-S1 through the foramina, transforaminal, and pedicle on the side of the 
discs bulge; the operative report does not support this. The operative report supports the procedure was 
performed in the standard fashion or through the lamina 
 
We looked at this coder'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 pay for procedure codes 63056 and 63057 rendered on March 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation (A0428). 
 
You asked the Plan to pre-approve non-emergent ambulance transportation. You say that the enrollee's 
transportation to the wound care center is for multiple pressure ulcers treatment. If he does not come to the 
wound care on a weekly basis, the ulcers will deteriorate, and he will be admitted to the hospital. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergent ambulance transportation have not been met. Specifically, Medicare does not cover 
ambulance rides to doctors office visits. Therefore, we decided that the Plan does not have to pre-approve non-
emergent ambulance transportation (A0428).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that the enrollee has tried Avastin, and it does not work. 
You say that the enrollee needs this medication to prevent the loss of their eyesight. The Plan denied your 
request. The Plan says that the step therapy requirements have not been met. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's preferred drug Byooviz. Also, there is no indication that the Plan's required drug 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous laser ablation therapy. 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has a mid-tibia wound 
and edema that is not healing. You also say that this is medically necessary. The Plan denied your request. The 
Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose 
veins are considered medically reasonable and necessary when an evaluation of the patient has been performed 
including a history and physical examination, the CEAP clinical classification and the revised Venous Clinical 
Severity Score (VCSS). 
 
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 outpatient procedure. Our reviewer 
says that the requested endovenous laser ablation therapy is not medically necessary. Our physician reviewer 
found the provided documentation does not include the CEAP class and VCSS score. The documentation does 
not meet guideline criteria for use of this therapy. Therefore, the reviewer found that the requested endovenous 
ablation therapy 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous laser ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that that the enrollee's pain is affecting 
their well-being and their ability to move around. You say that 15 minutes after the enrollee's genicular 
complex block procedure their pain improved 100%. The Plan denied your request. The Plan says the 
radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the radiofrequency ablation is the subject of ongoing clinical trials and is considered an 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 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624) and injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injections. You say that requesting reconsideration due to medical necessity. 
The Plan denied your request. The Plan says the request is not medically necessary because based on the 
medical literature this procedure is considered experimental or investigational and has not been proven to be 
beneficial for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve block is experimental and investigational for knee pain. More research is 
needed to show efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 
performed (64624) and injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including 
imaging guidance, when performed (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic treatment to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the chiropractic treatment. You say that you are looking for a specialist to 
help with your migraines. The Plan denied your request. The Plan says that chiropractic services are available 
with in-network providers. 
 
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 
chiropractic treatment to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on February 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99214-25 (1 unit) remains not supported. 
 
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 asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the history and examination are 
medically appropriate. However, the provided documentation does not sufficiently support this code as it does 
not support a moderate level of decision making or detail the encounter duration of 30-39 minutes as required.  
We looked at this coder'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 pay for evaluation and management services (procedure code 99214) rendered on February 15, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Avsola injections. 
 
You asked the Plan to pre-approve Avsola injections. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says that the requested drug does not meet the criteria for approval. 
 
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 Avsola injections. Our reviewer says 
that the requested drug, Avsola, meets the criteria for approval. Our physician reviewer found Avsola is 
biosimilar to infliximab. Avsola is FDA-approved for the treatment for Crohn's disease, and this enrollee has 
active Crohn's disease. Avsola as requested is medically necessary, safe, and appropriate 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 Avsola injections have been met. Therefore, we decided that the Plan has to 
pre-approve Avsola injections.  
 
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: 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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for the LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment but is still somewhat 
unstable and requires additional acute care hospital services that can safely be provided at the current facility 
until more stable and appropriate for transfer to a lower level of care.  The enrollee does not require services at the LTACH that are not already available 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular block. 
 
You asked the Plan to pre-approve the genicular block. The Plan denied your request. The Plan says the 
genicular nerve block 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 genicular block. Our reviewer says 
that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular nerve 
blocks are not shown to benefit patients with osteoarthritis of the knee. 
 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 genicular block have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genicular block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be admitted to an 
LTACH.  The Plan denied your request. The Plan says an LTACH admission 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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 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 LTACH services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that Botox is not 
medically necessary.  
 
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 the drug. Our reviewer says that Botox 
is medically necessary.  Our physician reviewer found that for the diffuse esophageal spasm (DES) that is 
recurrent, the requested use of Botox is warranted. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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.