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

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this procedure would provide 
long-lasting pain relief. The Plan denied your request. The Plan says the clinical value and effectiveness of a 
genicular artery embolization in the setting of knee osteoarthritis have not been demonstrated in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery embolization is as 
good as or better than standard treatments for knee osteoarthritis. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and ultrasound (78661) provided on 
October 20, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that this claim was submitted three times. You 
also say that this should be paid. The Plan denied your request. The Plan says the corrected claim was not filed 
timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until February 17, 2023. This means that more than one calendar year from the date of the initial determination or redetermination for any reason before 
a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit (99213) and 
ultrasound (78661) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc NP procedure (0627T). 
 
You asked the Plan to pre-approve a VIA Disc NP procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VIA Disc NP procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental/ investigational procedure as of 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 a VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a VIA Disc NP procedure (0627T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested treatment order of carboplatin is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 medication. Our reviewer says that 
that the requested drug combination is not supported. Our physician reviewer found the request is for 
carboplatin to be used in combination with atezolizumab, paclitaxel and bevacizumab for non-small cell lung 
cancer. The combination is not FDA approved for the enrollees diagnosis. The combination is also not 
supported by one of the major drug compendia or by clinical research. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve carboplatin.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits. 
 
You asked the Plan to pre-approve ten (10) additional physical therapy visits. You say that ten (10) additional 
physical therapy visits are medically necessary. The Plan denied your request. The Plan says ten (10) additional 
physical therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten (10) additional physical therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer that the enrollee has previously been treated 
with outpatient therapies and should be independent with a home exercise program. The additional therapy 
services are not an appropriate duration and frequency for treatment of the enrollees medical condition and 
therefore are not medically 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 ten (10) additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 30, 2022, to 
June 6, 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 
DRG that was reported should be paid. The Plan denied your request. The Plan says as J96.01 is not supported, 
the DRG was downgraded. 
 
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 secondary diagnosis code J96.01, defined as acute 
respiratory failure with hypoxia. 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 reported code J96.01 is not supported.  
Our physician reviewer found the enrollee is a female who was treated in the hospital for aspiration pneumonia 
causing a cough and was treated with antibiotics. Evaluation revealed oxygen saturation of 95% on room air 
without acute distress and with normal pulmonary effort according to the notes. The enrollee was not treated 
with high flow oxygen support or any other type of respiratory assistance. Therefore, the documentation does 
not support the code, J96.01, defined as acute respiratory failure with hypoxia as there was no significant 
hypoxia or respiratory distress.   
 
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 May 30, 2022, to June 6, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
6, 2022, to December 31, 2022. 
 You asked the Plan to pay for SNF care. You say that these services were medically necessary. The Plan denied 
your request. The Plan says the enrollee's condition no longer required daily skilled nursing or therapist 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 6, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves 
(64624). 
 
You asked the Plan to pre-approve RFA of the genicular nerves. 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 RFA of the genicular nerves. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. It is the 
subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the genicular nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96375 and J2250 rendered on May 1, 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 96375: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J2250: 
 
Injection, midazolam hydrochloride, per 1 mg 
 
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 procedure report describes a 
Versed (midazolam) injection given for sedation. In this case, these procedures would be included in the 
moderate sedation procedure code already reimbursed.  
 
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 96375 and J2250 rendered on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (77370, 
77373). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the request does not meet Medicare and/or plan policy because it is not a covered 
benefit. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT is generally only indicated for enrollees with oligometastatic 
disease of for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a 
state of metastatic disease with metastases few in number and extent. For this enrollee, the plan is to treat a 
dominant lung lesion in the setting of bilateral lung metastases that are seemingly small and well controlled. 
Certainly, palliative 3D radiation (perhaps dose escalated) could be offered as a standard of care approach 
which conceivably would have lower risks of side effects with no known detriment in cancer outcomes. The 
decision is unfavorable for SBRT and would be favorable for palliative RT with 3D conformal radiation and 
IGRT. 
 
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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT) (77370, 77373).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery and intraocular lens placement with 
aniridic prosthetic iris. 
 
You asked the Plan to pre-approve cataract surgery and intraocular lens placement. You say that the enrollee 
says that they have become overly dependent on others to assist them with daily activities. The Plan denied 
your request. The Plan says the plan says that this surgery 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 cataract surgery and intraocular lens 
placement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found congenital aniridia is not the reason for her gradual 
decline in vision the last few years as this defect was present at birth and its sequela most likely have affected her visual development at an early age permanently. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery and intraocular lens placement have not been met. Therefore, 
we decided that the Plan does not have to pre-approve cataract surgery and intraocular lens placement with 
aniridic prosthetic iris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) (77014, 
77331, 77370, 77387, 77470, 77520, 77523, 77525). 
 
You asked the Plan to pre-approve PBRT. You say that the enrollee has life-threatening right chest wall and 
regional lymph nodes cancer. It is medically necessary to treat her with a high dose of proton beam therapy in a 
post-operative setting to protect her heart, lungs, contralateral breast, and spinal cord. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and 
tolerability. While small studies have demonstrated the ability of proton therapy to reduce lung and cardiac (for 
left sided breast cancer) dose exposure, it is not clear if such reductions are clinically meaningful for proton 
therapy to be recommended for general use. When treating patients with complex target volumes and/or when 
needing to treat internal mammary, supraclavicular and axillary nodes, proton therapy may yield a better dose 
distribution that is clinically meaningful Despite the uncertainty of any benefit of proton therapy for use in the 
general population, there is some understanding about acceptable lung and heart exposure relative to risk of 
toxicity. For this enrollee, the records describe a case control comparison plan with no comparison of proton 
therapy vs. an optimally designed volumetric modulated arc therapy (VMAT) (i.e., using deep inspiration 
breath hold and optimal selection of beam angles). The decision in this case is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT) (77014, 77331, 77370, 77387, 77470, 77520, 77523, 
77525).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you say that you have pain in your feet. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 appropriate care in current acute care setting. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records do not include a PDL1 result to 
determine if the requested drug is 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.