Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the enrollee would like to receive Botox to help with 
their pelvic pain. The Plan denied your request. The Plan says the criteria for coverage are not met and the 
Botox is not reasonable or 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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of chronic pelvic pain. The FDA has not stated that the requested drug is indicated 
for the enrollee's condition. Our reviewer found that 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 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve onabotulinumtoxina (Botox) (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 19, 2022, to July 
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 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not supported. 
 
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 G93.41, defined as metabolic encephalopathy. 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 documentation does not support the services billed. Our physician 
reviewer found the enrollee was admitted to the hospital with nausea with vomiting. The enrollee was 
diagnosed and treated for acute kidney injury and a urinary tract infection. The documentation indicates the 
enrollee was alert and appropriately oriented. The documentation does not indicate that the enrollee had 
significant confusion during the hospital stay. The documentation does not consistently and completely support 
the assigned secondary diagnosis code. Therefore, the DRG billed is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 19, 2022, to July 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fitted mandibular sleep apnea appliance 
(E0486). 
 
You asked the Plan to pre-approve an oral sleep apnea appliance. You say that the enrollee travels and spends 
summers in the outdoors, camping where there is no power supply for the CPAP machine. The Plan denied 
your request. The Plan says the oral appliance is requested as a convenience item for the enrollee therefore, the 
oral appliance is not covered as 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 an oral sleep apnea appliance. 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 medical records provided there is no documentation that the 
custom-fitted mandibular sleep apnea appliance E0486 at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided records in this case contain conflicting 
information as to whether the patient has tried and failed a positive airway pressure (PAP) device. One note in 
the records indicates the enrollee has tried and failed a PAP and another statement indicates the enrollee has 
not. There is no indication from the treating practitioner that the use of a PAP device is contraindicated. The 
criteria for coverage of the device are not met, as required by the Local Coverage Determination - Oral 
Appliances for Obstructive Sleep Apnea (L33611). 
 
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 oral sleep apnea appliance have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a custom-fitted mandibular sleep apnea appliance (E0486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dynasplint device. 
 
You asked the Plan to pre-approve a Dynsplint device. You say that the requested Dynasplint is medically 
necessary.  The Plan denied your request. The Plan says the requested Dynasplint 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 a Dynsplint device. Our reviewer says 
that the requested Dynasplint is not medically necessary.  Our physician reviewer found independent review of 
literature in the national library of medicine found significant concerns about efficacy and effectiveness of a 
dynamic brace system when compared to other modalities. Per SSA 1862 (a)1(A) the device has not been 
shown to be effective for the enrollee's condition. 
 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 Dynsplint device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dynasplint device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal instrumentation procedures on the spine and 
interspinous process distraction device (implantable). 
 
You asked the Plan to pre-approve spinal instrumentation procedures on the spine and interspinous process 
distraction device (implantable). You say that spinal instrumentation procedures on the spine and interspinous 
process distraction device (implantable) are medically necessary. The Plan denied your request. The Plan says 
spinal instrumentation procedures on the spine and interspinous process distraction device (implantable) are 
unproven and 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 spinal instrumentation procedures on 
the spine and interspinous process distraction device (implantable). Our reviewer says that the requested spinal instrumentation procedures on the spine and interspinous process distraction device (implantable) are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the spinous 
distraction device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal instrumentation procedures on the spine and interspinous process 
distraction device (implantable) have not been met. Therefore, we decided that the Plan does not have to pre-
approve spinal instrumentation procedures on the spine and interspinous process distraction device 
(implantable).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital swing bed services provided from November 8, 
2022, to November 14, 2022. 
 
You asked the Plan to pay for hospital swing bed services. You say that these services were medically 
necessary and are supported in the medical records. The Plan denied your request. The Plan says these services 
were not billed with an appropriate rate code. 
 
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. The rules also say that providers must report services correctly. Skilled 
nursing facility services and hospital swing bed services must be reported with a 5-digit "HIPPS Code". 
 
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 hospital swing bed services have been 
met. Specifically, the claim submitted in this case is for hospital swing bed services, but a diagnosis related 
group (DRG) rate code is submitted. Per Medicare guidelines, hospital swing bed services are required to 
report inpatient Part A prospective payment billing with a 5-digit HIPPS code instead of a DRG code. 
Therefore, we decided that the Plan does not have to pay for hospital swing bed services provided from 
November 8, 2022, to November 14, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). We decided that the 
Plan does not have to pre-approve special radiation treatment (code 77470).  
 
You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT) and special radiation treatment 
(code 77470). You say that the enrollee meets the criteria. The Plan says that that the services are not medically 
necessary or covered by Medicare or the Plan. 
 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).  
 
The Plan follows 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 stereotactic body radiation therapy 
(SBRT) and special radiation treatment (code 77470). Our reviewer says that the enrollee meets criteria for 
SBRT. Our physician reviewer found that SBRT is an accepted standard of care for spine metastases in select 
patients. SBRT for limited sites of metastatic disease would be in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
SBRT.  
 
We also decided that the Plan does not have to pre-approve special radiation treatment (code 77470). 
 
The Plan follows 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 simulation-aided field setting. Our 
reviewer says that the enrollee does not meet criteria for special radiation treatment (code 77470). Our 
physician reviewer found that the records did not justify the need for billing 77470, which requires 
documentation to support this code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of special radiation treatment (code 77470) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve special radiation treatment (code 77470). 
 
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 pay for inpatient hospital services provided on June 8, 2022, to June 
9, 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 the 
medical records support the billing of secondary diagnosis code I50.33.  The Plan denied your request. The 
Plan says the medical records do not support the billing of secondary diagnosis code I50.33.  
 
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 I50.33. 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 medical records do not support the billing of secondary diagnosis code I50.33.  Our physician reviewer 
found the review indicates that acute congestive heart failure was documented, confirmed in a query, telemetry 
was ordered along with IV Lasix, daily weight, strict intake and output, a daily electrocardiogram was ordered, 
and Cardiology was following. There was no clinical or laboratory evidence of chronic diastolic (congestive) 
heart failure. The review has determined that the documentation did not support I50.33.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 8, 2022, to June 9, 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 a Verteflex/Superion Interspinous Spacer System 
procedure. 
 
You asked the Plan to pre-approve a Verteflex/Superion Interspinous Spacer System procedure. You say that 
you are in a lot of pain and need this procedure. The Plan denied your request. The Plan says this procedure to 
be 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 a Verteflex/Superion Interspinous 
Spacer System procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline 
and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollees medical condition. 
 
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 Verteflex/Superion Interspinous Spacer System procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Verteflex/Superion Interspinous Spacer 
System procedure.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says that Zilretta, is 
intended for one time use according to the prescribing information. The Plan also says that a generic steroid 
such as triamcinolone could be used instead of the brand drug Zilretta. 
 
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. Our reviewer says that the 
documentation supports that the requested use of Zilretta is FDA-approved for the enrollees diagnosis. Our 
physician reviewer found Zilretta (triamcinolone acetonide extended-release injectable suspension) is indicated 
as an intra-articular injection for the management of osteoarthritis pain of the knee. The product label states, 
"Limitation of Use: The efficacy and safety of repeat administration of Zilretta have not been demonstrated." 
Our reviewer found based on the Label, it does not preclude use of the drug more than one time. Our reviewer 
also found that in addition, based on the regulation 50.4.1 - Approved Use of Drug, drugs or biologicals 
approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for 
purposes of this requirement when used for indications specified on the labeling. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta (J3304).  
 
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 pay for rotary wing air transport and rotary wing air mileage 
provided on September 22, 2022.  
You asked the Plan to pay for the rotary wing air transport and rotary wing air mileage. You say that the 
submitted records support this was an emergency transport and this was the closest facility to treat the enrollee 
at the time of transport. The Plan denied your request. The Plan says there is no documentation in the clinical 
record documenting any reason required services were not available or could not be utilized to treat the 
members medical condition. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and rotary wing 
air mileage . Our reviewer says that the air ambulance transport services were not medically necessary. Our 
physician reviewer found the transfer was conducted at the family's request, not because the enrollee required 
services that were not locally available. As such, the transfer was not medically necessary and is, therefore, not 
coverable. 
 
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 rotary wing air transport and rotary wing air mileage  have not been met. 
Therefore, we decided that the Plan does not have to pay for rotary wing air transport and rotary wing air 
mileage provided on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for procedure code P9603. You say that this service was reported correctly. The Plan 
denied your request. The Plan says this service is not supported in the medical record. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, there is no documentation 
provided relating to any kind of travel in connection with the laboratory services provided. Based on this information, we decided that Medicare rules for coverage of procedure code P9603 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code P9603 billed for date of service 
January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet 
injections 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 facet joint injections to be provided by an out-of-network (OON) provider.