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

 
We decided that the Plan does not have to pre-approve Darzalex Faspro (J9144) and Decitabine (J0894). 
 
You asked the Plan to pre-approve Darzalex Faspro and Decitabine. 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 Darzalex Faspro and Decitabine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested use of 
Darzalex Faspro and Decitabine is not FDA-approved for the enrollees diagnosis. The approved compendia were reviewed and there was no supportive literature for this specific regimen applied to the enrollee's specific 
condition. Therefore, the documentation does not sufficiently support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this 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 Darzalex Faspro and Decitabine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Darzalex Faspro (J9144) and Decitabine (J0894).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related 
supply allowance. 
 
You asked the Plan to pre-approve the CGM and the related supply allowance. You say that the requested 
CGM is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria 
was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and the related supply 
allowance. Our reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that 
the coverage criteria require insulin use or low blood sugars for the CGM coverage. This enrollee is not having 
low blood sugars that we are told of nor is the enrollee on medications that typically cause low blood sugars. 
The enrollee is not using insulin. We are not told why a fingerstick meter is not sufficient for this enrollee at 
this time. 
 
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 CGM and the related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related supply 
allowance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA) (64624).  
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has had these in the past. You say that 
the enrollee has received 85% pain relief and knee has significantly improved. The Plan denied your request. 
The Plan says this service is not indicated for chronic knee pain. 
 
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 RFA. Our reviewer says that the 
requested genicular nerve RFA is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. The reviewer found this is the subject of 
ongoing clinical trials. Therefore, the reviewer found that the requested RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genicular nerve radiofrequency ablation (RFA) (64624).
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 services are medically necessary for 
the enrollee's medical needs. The Plan denied your request. The Plan says the services are 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 the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied.  
 
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: 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 this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Byooviz. 
 
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 the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drug, Byooviz. The reviewer also found that there is no 
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 28, 2022, to 
May 4, 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 original DRG billed. The Plan denied your request. The Plan says the medical 
records do not support the billing of primary diagnosis A41.9 (Sepsis, unspecified organism) and secondary 
diagnosis J69.0 (Pneumonitis due to inhalation of food and vomit). As a result, a lower DRG was paid. 
 
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 primary diagnosis A41.9 (Sepsis, unspecified 
organism) and secondary diagnosis J69.0 (Pneumonitis due to inhalation of food and vomit). 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 primary diagnosis A41.9 (Sepsis, unspecified organism) and secondary diagnosis J69.0 
(Pneumonitis due to inhalation of food and vomit) are not supported by the medical record. Our physician 
reviewer found the enrollee is an 81-year-old female who presented with moderate to severe dysphagia and 
workup confirmed dysphagia on a swallow study, but no aspiration or pneumonia was identified. Following 
initial fluids, the enrollee had stable vitals, no oliguria, no evidence of abnormal Glasgow Coma Scale (GCS) 
score, and there were normal platelets, normal bilirubin, and no hypoxia noted. The criteria for Sepsis 3 were 
not met, and there was no evidence of a dysregulated response to systemic infection leading to organ failure as 
required to justify the code, A41.9 (sepsis). Also, there was no evidence of pneumonitis with objective 
assessments to justify the code, J69.0 (pneumonitis due to inhalation of food and vomit).  
 
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 April 28, 2022, to May 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a in house rehabilitation facility, 
and has a prior active lifestyle and will not get back to the level she was at a skilled nursing facility. The Plan 
denied your request. The Plan says the enrollee's records do not show the need for an intensive team for care. 
The Plan says that the services needed may be provided safely in a lower level of care.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve a lower denture. You say that you cannot eat and cannot afford the denture. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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 record 
shows your benefit for the requested item or service was exhausted on date of service December 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142) billed for date of service 
February 1, 2023. 
 You asked the Plan to pay for anesthesia services. You say that this service was billed appropriately and is 
payable. The Plan denied your request. The Plan says the date of service submitted for the anesthesia services 
is not supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also 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. 
 
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 anesthesia services have been met. 
Specifically, the only records provided are for a date of service of January 31, 2023. No records were provided 
which reflect a date of service of February 1, 2023; therefore, services billed for this date cannot be supported. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (00142) billed for date of 
service February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device (22612). 
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Minuteman interspinous device in 
the setting of back pain 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 the Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature for 
(existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, 
there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that 
have not been fully documented as having been excluded and/or ruled out. 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device (22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an 
appropriate product to be used for knee arthritis. 
 
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 this is considered experimental/investigational therapy. There are ongoing 
clinical trials of this technique. 
 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 genicular artery embolization (36246, 36247).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 30, 2022, to August 
28, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 30, 2022. The NOA was not received by the Plan until May 9, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
July 30, 2022, to August 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service June 13, 
2023. 
 
You asked the Plan to pay for procedure code 64447. You say that you have billed the services at issue 
correctly.  The Plan denied your request. The Plan says payment for code 64447 is bundled into payment for 
code 01400. 
 
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 64447 is: Injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, including imaging guidance, when performed. 
 
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 procedure code 64447. Our reviewer says that procedure 
code 64447 does not meet criteria for payment. Our reviewer found that code 64447 was billed with modifier 
RT, indicating the procedure was performed on the right side. The provided medical record states that the 
procedure was performed on the left side. There is a more appropriate way to report this laterality. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64447 billed for date of service June 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from  
November 19, 2022, to November 22, 2022, at the Diagnosis Related Group (DRG) 871 originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at DRG 871 originally billed. You say that the 
medical records support diagnosis code A41.9, sepsis, unspecified organism. The Plan denied your request. The 
Plan says diagnosis code A41.9, sepsis, unspecified organism, is not supported by the medical records. 
 
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 diagnosis code A41.9, sepsis, unspecified organism.   
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 DRG 871 
originally billed. Our reviewer says that the inpatient hospital services originally billed with DRG 871 do not 
meet the coverage criteria. Our physician reviewer found the enrollee presented to the hospital with chest pain, 
shortness of breath. The workup revealed stable vitals, computed tomography (CT) suggestive of pneumonia, 
electrocardiogram (ECG) with atrial flutter, variable A-V block, and was given Cardizem and Amiodarone drip 
and was later cardioverted. The enrollee had leukocytosis, normal platelets, normal creatinine, and was oriented 
x 3. Blood cultures showed no growth, sputum culture revealed gram positive cocci. No bilirubin test was 
found in the notes. Given the provided documentation suggesting no systemic infectious process, only localized 
pneumonia, no evidence of organ failure related to a dysregulated response, the Sepsis 3 criteria was not met 
for this admission. Therefore, the code, A41.9 (sepsis) 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 from November 19, 2022, to November 22, 2022, at DRG 871 
originally billed.