Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches. 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 destruction by neurolytic agent, 
genicular nerve branches. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 destruction by neurolytic agent, genicular nerve branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular 
nerve branches including imaging guidance (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that the enrollee has no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on electrocardiographic (ECG) monitoring. A recent randomized clinical 
trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR) (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a genicular nerve RFA. You say that this procedure is medically necessary 
to manage the enrollee's chronic pain. You say you are confident that it will significantly improve the enrollee's 
quality of life. The Plan denied your request. The Plan says the request 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 genicular nerve RFA. 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 documentation that the genicular nerve RFA at issue in this case 
meets all Medicare criteria for medically reasonable and necessary and safe and effective for the enrollee. The 
provided medical records and review of the current peer-reviewed medical literature do not document that use 
of genicular nerve RFA has been shown in controlled studies in a CMS-approved journal to result in sustained 
long term health benefits in the Medicare population with knee pain and osteoarthritis of the knee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve radiofrequency ablation (RFA).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on June 29, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the records support an appropriate history and physical were obtained; However, the medical decision making 
was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 13, 
2023. 
 You asked the Plan to pay for procedure code 88342. The Plan denied your request. The Plan says payment for 
code 88342 is bundled into payment for code 88361. 
 
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, we have confirmed that code 88342 
is a column II code to column I code 88361. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you have arthritis and you cannot get up 
from the toilet due to pain. The Plan denied your request. The Plan says raised toilet seats are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. The Plan denied your request. The Plan says the 
requested code E2311 does not primarily serve a medical purpose. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is deconditioned with multiple chronic illnesses, including Chronic 
Obstructive Pulmonary Disease (COPD). The enrollee has 3 out of 5 strength bilaterally in their upper 
extremities. Our reviewer also found that an electronic connection is not medically necessary as the enrollee 
has adequate strength to manage standard power drives. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 19, 2023, billed with 
procedure codes 64447-59-RT and 64450-59-RT. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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, we have confirmed that codes 64447-59-RT and 64450-59-RT are column II codes to column I 
code 01402; however, 64447-59-RT and 64450-59-RT were billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical record does not include 
sufficient documentation to support anesthesia was not dependent on injection service billed. These procedure 
codes and modifiers cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 19, 2023, billed with procedure codes 
64447-59-RT and 64450-59-RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the follow-up nursing facility visit and chronic care 
management services provided on April 06, 2023, to April 30, 2023. 
 
You asked the Plan to pay for the follow-up nursing facility visit and chronic care management services. You 
say that the services were medically necessary. 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 the follow-up nursing 
facility visit and chronic care management services provided on April 06, 2023, to April 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for placement of radiation therapy 
(IGRT) fields (procedure G6001) rendered on April 20, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful when treating with electron beam, 
[superficial radiotherapy], or skin surface brachytherapy. 
 
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 there is insufficient long-term efficacy and safety data to support routine use of electronic surface 
brachytherapy. However, the treatment itself is not disputed in this case but rather the need for image guidance. Usually IGRT is used when critical structures are abutting or in close proximity to the target that is being 
treated to high doses. This situation does not apply to this patient for which the target lesion can be seen on the 
skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep 
structures are being treated. Certainly using ultrasound on a daily basis is not unreasonable to offer but not 
necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound though 
that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to 
incorporate this functionality. Therefore to bill for daily simple simulations and/or IGRT for a technology for 
which need has not been established by published data or supported by consensus guidelines (many of which 
recommend against treatment with these devices in general- citations below) is not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ultrasonic guidance for placement of radiation therapy (IGRT) fields (procedure G6001) 
rendered on April 20, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the 
requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a 
trial of Infed and Venofer before they will approve Injectafer. In this case, the enrollee has not tried and failed 
the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely 
be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to use her arms or legs and 
will be helpless if she is discharged to home. The Plan denied your request. The Plan says that request for 
approval of continued admission in skilled nursing facility does not meet the requirements for approval. 
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 26, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided on July 1, 2023, to July 29, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON dialysis services. You say that you are a Medicare-certified provider, 
and the Plan must cover these services. The Plan denied your request. The Plan says the services were available 
from network providers, and no authorization was obtained for OON care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. These dialysis services were not 
provided out of the service area. The Plan did not pre-approve the item/service at issue. We found no exception 
that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to 
pay for the dialysis services provided on July 1, 2023, to July 29, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth rehabilitation and treatment of temporal 
mandibular joint syndrome or dysfunction. 
 
You asked the Plan to pre-approve dental services. You say that you are in pain and discomfort. There is no 
other provider in your area that can handle the requested procedure. The Plan denied your request. The Plan 
says the requested dental procedure is not a covered service under your plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a full 
mouth rehabilitation and treatment of temporal mandibular joint syndrome or dysfunction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004) and 
accessories (E2201, K0108, E2611, E0990, K0040, E0961, E2211, E2213, E0973, E0971, E0978, E2601). 
 
You asked the Plan to pre-approve a lightweight wheelchair and accessories. You say that the enrollee requires 
a high strength lightweight manual wheelchair for mobility needs. The Plan denied your request. The Plan says 
back-up (second) wheelchairs are not covered. Items for appearance, convenience, or comfort are not 
considered 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 lightweight wheelchair and 
accessories. 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 obesity and impaired weight bearing with 
a chronic wound in her left leg. She has a 3-year-old power wheelchair. Per L33789, the manual wheelchair is 
not medically necessary for self-care in the home. 
 
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 lightweight wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004) and 
accessories (E2201, K0108, E2611, E0990, K0040, E0961, E2211, E2213, E0973, E0971, E0978, E2601).