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

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you are requesting an expedited reconsideration for 
the denial of Orthovisc. You say the enrollee is in pain without the injection. The Plan denied your request. The 
Plan says based on Medicare guidelines, the enrollee does not meet all the requirements.  
 
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 injection. Our reviewer says that the 
service is not medically reasonable or necessary. Our physician reviewer found there is no documentation 
provided indicating that the enrollee has failed at least three months of conservative therapy. The review has 
determined that the requested use of Orthovisc is not FDA-approved for the enrollees diagnosis and does not 
support that Orthovisc is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units for procedure codes 95938 and 95861 
rendered on April 4, 2022. 
 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 additional units cannot be 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. 
 
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 documentation does not 
support the codes in question. There is no evidence that a diagnostic needle electromyography (EMG) for 
somatosensory evoked potentials (SSEP) was performed with a physician's interpretation. The record contains 
intraoperative neuromonitoring readings only. 
 
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 additional units for procedure codes 95938 and 95861 rendered on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve referral to out-of-network hematologist/oncologist 
(diagnose and treat tumors and disorders of the blood).  
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says while the enrollee's treatment may be medically necessary, it does not 
appear urgent/emergent and the Plan will not approve out-of- network for established care. The Plan states if 
the enrollee has moved from this service area then the enrollee  
may need to change plans. 
 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. The Plan states the enrollee has moved from their coverage area in 
Missouri to Michigan and was advised that the enrollee would need a different plan for coverage in Michigan. 
Therefore, we decided that the Plan does not have to pre-approve referral to out-of-network 
hematologist/oncologist (diagnose and treat tumors and disorders of the blood).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve destruction (64624). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there are not enough studies on genicular nerve destruction to show that it is 
safe and effective; therefore, it is not considered standard of care. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) is the subject of ongoing 
clinical trials. It is considered experimental at this time. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve destruction (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMs are still on an experimental/research phase and not recommended 
by any society/association heart failure management guidelines. 
 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs was approved by the 
Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in the enrollee's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of substance into lower spine canal using 
imaging guidance (62323). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records do 
not show documentation of at least 50 percent sustained improvement in pain for at least three (3) months 
duration before a second injection. The Plan states the enrollee's records indicate that the enrollee had no pain 
relief after the enrollee's March 24, 2023, injection 
 
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 injection. Our physician reviewer 
found the LCD criteria requires at least 50 percent pain relief for three (3) months; however, this was not 
achieved. 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection of substance into lower spine canal using imaging guidance (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (cutaneous squamous cell carcinoma), mRNA gene 
expression profiling by RT-PCR of 40 genes (DecisionDX-SCC) rendered on November 22, 2022. 
 
You asked the Plan to pay for the services. You say that the test is a proprietary, 40 gene expression profile test 
with 4 peer reviewed publications involving over 400 patients and over 500 clinicals. The Plan denied your 
request. The Plan says the information submitted with the request gives no information about enrollee 
preference or ability to give consent at extreme age. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the use of molecular profiling to determine the need for additional treatment is not a standard of care 
for the treatment of cutaneous squamous cell carcinoma. This use is not supported by the National 
Comprehensive Cancer Network (NCCN) guidelines or the medical literature. How this testing would impact 
care is unclear. 
 
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 pay for oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR 
of 40 genes (DecisionDX-SCC) rendered on November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care billed on December 13, 2021, to December 18, 
2021, billed with secondary diagnosis codes I13.0 and I50.33. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says that medical records were not provided to 
support the billed diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the denial rationale offered by the plan is not supported. Upon 
review of the documentation provided, we find that secondary diagnosis codes I13.0 and I50.33 are supported. 
Therefore, we decided that the Plan has to pay for inpatient hospital care billed on December 13, 2021, to 
December 18, 2021, billed with secondary diagnosis codes I13.0 and I50.33.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept 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 an Intracept 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 no magnetic resonance imaging (MRI) showing only modic changes and 
foraminal stenosis or facet degenerative joint disease (djd). 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on January 24, 2023. 
 
You asked the Plan to pay for pathology services. You say that the doctors office failed to get authorization. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pathology services 
provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81404, 81405, 81406, 81407). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of 
these tests. The requested services are not consistent with the standard of care. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has a diagnosis of autism with intellectual disability and dystonic tremor. Based on 
the medical records provided and the Local Coverage Determination (LCD) Molecular Pathology Procedures 
L35000 the requested molecular pathology panels (level 5, 6, 7, 8) (81404, 81405, 81406, 81407) do not meet 
Medicare criteria for coverage. The requested panels all contain components that are cited as "unlikely to 
impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care 
of the beneficiary and will be denied as not medically necessary" in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81404, 81405, 81406, 81407).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery (procedure codes 13100 and 15836). 
 
You asked the Plan to pre-approve the services. 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the requested procedures would be considered primarily cosmetic in this case. There is insufficient 
documentation of complicating factors such as inability to walk normally, chronic pain, ulceration created by 
the skin folds, or intertrigal dermatitis, and that the symptoms have been present for at least three months and 
are refractory to usual standard medical therapy. 
 
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 plastic surgery (procedure codes 13100 and 15836).
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 records provided support medical 
necessity. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - mandibular (D5140), immediate 
denture - maxillary (D5130), unspecified removable prosthodontic procedure, by report (D5899), and 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on September 
22, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D5140, D5130, D5899 and D7140. You 
say that you were supposed to have $2000.00 in dental coverage for the year 2022 and more specifically, was 
supposed to have $2000.00 in dental coverage toward dentures.  You also don't understand why this was denied.  The Plan denied your request. The Plan says your benefit for 
the extraction, erupted tooth or exposed root (D7140) has already been exhausted. The Plan also says  the 
dental services represented by codes D5140, D5130, D5899 are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The dental 
services represented by codes D5140, D5130, D5899 are not among those covered under this benefit. The 
record shows your benefit for extraction, erupted tooth or exposed root D7140 was exhausted on date of service 
September 22, 2022. Therefore, we decided that the Plan does not have to pay for an immediate denture - 
mandibular (D5140), immediate denture - maxillary (D5130), unspecified removable prosthodontic procedure, 
by report (D5899), and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided on September 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive therapy in order to 
return home safely in a timely manner. The Plan denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.