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

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. 
 
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 nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen genetic testing provided on May 13, 2022, 
billed with code 87506. 
 
You asked the Plan to pay for the testing as billed. You say that this was medically necessary testing.  The Plan 
denied your request. The Plan says the code billed is not supported.  
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
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 testing as billed. Our reviewer says that the code reported 
in this case is not supported by the record.  Our reviewer found the provided report does not support testing of 
6-11 targets. There is a more appropriate code for the services rendered.  
 
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 testing as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the pathogen genetic testing provided on May 13, 2022, billed with code 87506.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the enrollee needs this medication.  The Plan denied 
your request. The Plan says that the 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found that the enrollee has osteoarthritis of the 
knee, and the requested medication is a new start. However, there is no indication that the enrollee has tried and 
failed the Plan's preferred step one alternative. Also, there is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraocular Panoptix lens. 
 
You asked the Plan to pre-approve the intraocular Panoptix lens. You say that this lens will greatly enhance 
your vision distance when driving at night. You say the lens will enhance your vision and will no longer need 
glasses for reading.  The Plan denied your request. The Plan says the intraocular Panoptix lens is not medically 
necessary. The Plan says there is no additional documentation that justifies this request. 
 
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 intraocular Panoptix lens. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the presbyopia correcting intraocular lenses are not covered. There is no 
documentation that you could not get a standard monofocal intraocular lens and use glasses for correction.   
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 intraocular Panoptix lens have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the intraocular Panoptix lens.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve the requested services. You say that the aggressive treatment cannot be 
obtained on a short observation visit. The Plan denied your request. The Plan says the enrollee does not require 
an inpatient level of care.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 services. Our physician 
reviewer found that the enrollee has a past medical history of chronic migraine, anxiety, depression, panic 
disorder, hypertension, prediabetes, congenital pyloric stenosis, and gastroesophageal reflux disease. The 
enrollee now has intractable migraine. This request is for an inpatient admission for Botox to treat the 
migraines. There is no documentation that the enrollee has dysphagia, paresis or paralysis, or associated 
seizure. The records, with supporting documentation of the patients history and comorbidities, signs and 
symptoms, current medical needs, and risk of an adverse event, do not show that the enrollees necessary 
hospital care (including earlier ED and/or observation care) will span two midnights. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca.  
 You asked the Plan to pre-approve Udenyca. The Plan denied your request. The Plan says that the 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 Udenyca. Our reviewer says that 
Udenyca is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Fulphila or Neulasta. Also, there is no indication that the Plan's required drugs would 
likely be less effective or likely 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says it 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block is experimental for knee pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a walker with an enclosed frame (E0144). 
 
You asked the Plan to pre-approve  a walker with an enclosed frame. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for a walker with an 
enclosed frame (E0144) has not been established. Therefore, if an enclosed frame walker is provided, it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walker with an enclosed frame have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  a walker with an enclosed frame (E0144).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 23, 
2023.  
 
You asked the Plan to pay for procedure code 99291. You say that the enrollee was seen twice on the same 
date. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service March 23, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q5003 billed for date of service February 1, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an inappropriate 
place of service code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The file shows that the claim was submitted with Type of Bill 323. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code Q5003 billed for date of service 
February 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9123, S9131 billed for date of service 
November 10, 2022, to November 22, 2022. 
 
You asked the Plan to pay for procedure code S9123, S9131. You say that you disagree with the denial and 
request the claim to be reprocessed correctly for payment. The Plan denied your request. The Plan says the 
billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code S9123, S9131 has a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code S9123, S9131 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code S9123, S9131 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code S9123, S9131 billed for date of service 
November 10, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ganglion impar block.  
 
You asked the Plan to pre-approve the ganglion impar block. You say that the procedure is medically necessary  
The Plan denied your request. The Plan says the ganglion impar block 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 ganglion impar block. Our reviewer 
says that the ganglion impar block is not medically necessary. Our physician reviewer found that the enrollee is 
unsure what degree of relief they obtained and there is no documentation of the percentage relief that was 
obtained. While the ganglion impar block and neurolysis is well described, the radiofrequency ablation would 
be experimental and investigational. Therefore, the request is 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 ganglion impar block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the ganglion impar block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee suffers from multiple 
comorbidities including chronic obstructive pulmonary disease (COPD) that has gradually caused chronic 
respiratory compromise.  The Plan denied your request.  The Plan says a home ventilator is not medically necessary for the enrollee because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee had a recent 
hospitalization that showed successful treatment and therapy with BiPAP. There is not failure of BiPAP with or 
without AVAPS. The enrollee has supporting arterial blood gas (ABG) which showed improved acidosis and 
reduction of CO2, hence, premature for the home ventilator.  
 
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 home ventilator have been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 16, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 81456 
billed for date of service February 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve home health skilled nursing services. You say that the enrollee needs 
aggressive in-home nursing care and close observation of their wounds.  The Plan denied your request. The 
Plan says based on Medicare guidelines, the home health services requested do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the enrollee does not have documented skilled nursing needs (i.e., intravenous, complex wound care, and new 
ostomy). As such, home health skilled nursing services are not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing services.
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 IRF services are necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF.  
 
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.