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

 
We decided that the Plan does not have to pre-approve L2-L5 oblique lateral lumbar interbody fusions with 
placement of interbody cages, and robot assisted L2-L5 post-lateral fusion, L2-L5 posterior spinal 
instrumentation, use of robotic-assisted stereotactic navigation. 
 
You asked the Plan to pre-approve the surgical services. You say that these procedures are necessary to correct 
the enrollee's spinal deformity. The Plan denied your request. The Plan says a posterior fixation device when 
used during an anterior fusion surgery is considered experimental and/or unproven and therefore cannot be 
covered. 
 
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 surgical services. Our reviewer says 
that the requested surgical services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding instability demonstrated on dynamic 
flexion/extension films. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested L2-5 oblique lateral lumbar interbody fusion with cages and robot-assisted L2-5 posterolateral 
fusion, L2-5 posterior spinal instrumentation, and use of robotic-assisted stereotactic navigation 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L2-L5 oblique lateral lumbar interbody fusions with placement of interbody 
cages, and robot assisted L2-L5 post-lateral fusion, L2-L5 posterior spinal instrumentation, use of robotic-
assisted stereotactic navigation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular knee nerve block. 
 
You asked the Plan to pre-approve a genicular knee nerve block. You say that the requested genicular knee 
nerve block is medically necessary. The Plan denied your request. The Plan says the requested genicular knee 
nerve 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 a genicular knee nerve block. Our 
reviewer says that the requested genicular knee nerve block is not considered medically reasonable and 
necessary. 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. The review has determined that the requested genicular nerve block 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 a genicular knee nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular knee nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza (J7336). 
 
You asked the Plan to pre-approve Qutenza. You say that this is medically necessary for treatment of the 
enrollee's condition. The Plan denied your request. The Plan says no support was found for the requested use of 
this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Qutenza. Our reviewer says that the 
requested use of Qutenza is not medically necessary. Our physician reviewer found the requested use of this 
drug is not approved by the Food and Drug Administration (FDA) for the enrollee's condition. The reviewer 
also found that there is insufficient support in the medical literature for the use of Qutenza in the treatment of 
nonspecific hereditary and idiopathic neuropathy. Therefore, the reviewer found that the requested use of Qutenza 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 Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza (J7336).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for May 1, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 99223 
provided on May 1, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for 
May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99349 billed for November 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 99349 
provided on November 3, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99349 billed for 
November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 1, 2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you have billed the services at issue 
correctly. 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 May 1, 2023.
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 this care to gain independence. 
The Plan denied your request. The Plan says the enrollee does not require IRF services, and care can be 
provided at another 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 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.  
 
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: 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 you would benefit from IRF services. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, your 
needs can be provided at another setting.  
 
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 you do 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.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on March 8, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says insufficient information was provided to support this claim. 
 
The Plan must follow Medicare rules. Medicare rules 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 the drug testing have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the drug testing provided on March 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99348 for date of service May 15, 2023. 
 
You asked the Plan to pay for procedure code 99348. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 In this case, we have confirmed that I73.9 (Peripheral vascular disease, unspecified) has an Excludes1 note in 
relation to I70.238 (Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg). 
This means that the two diagnosis codes cannot be reported together. Based on this information, we decided 
that the Medicare billing rules for procedure code 99348 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99348 for date of service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive, non-implanted continuous glucose 
monitor (CGM) (E2103). 
 
You asked the Plan to pre-approve a One Touch Veri CGM. You say that you disagree with the denial. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a One Touch Veri CGM. Therefore, we decided that the Plan does not have to pre-approve a non-
adjunctive, non-implanted continuous glucose monitor (CGM) (E2103).
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 it is medically necessary for the enrollee to receive 
the requested level of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for admission to an IRF.  
 
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 enrollee is medically stable. There are no acute rehab skilled nursing needs 
identified or documented. At the current functional level, the enrollee does not need specialized intensive 
therapies. Document does not support necessity for admission to an IRF due to lack of acute medical acuity or 
nursing needs in addition to high functional level. The enrollees rehab needs can be provided in an alternate 
and low intensity setting such as in a skilled nursing facility with intermittent therapies or in-home with 
services.  
 
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: 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 you had surgery on your right femur and require 
additional rehabilitation and physical therapy to regain your independence .You say that a skilled nursing 
facility cannot provide the right level of physical therapy you need. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition solution provided on December 1, 
2022, to December 31, 2022. 
 
You asked the Plan to pay for the parenteral nutrition solution. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the submitted documentation did not include a receipt or proof of delivery of the supply for the 
billed dates of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the parenteral 
nutrition solution provided on December 1, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you have had this wound for seven 
years and none of the treatments or medications have helped except for hyperbaric oxygen therapy. The Plan 
denied your request. The Plan says the medical records show that your wound is suspected to be due to venous 
insufficiency, which is not a covered condition for hyperbaric oxygen therapy. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered when the 
criteria listed in the Medicare rule section of this decision are met. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested hyperbaric oxygen therapy is not medically necessary in this case. Our 
physician reviewer found that the provided medical records in this case do not document a covered indication 
for hyperbaric oxygen therapy as detailed in the Medicare NCD. You have a chronic ulcer due to venous 
stasis/insufficiency. The Medicare NCD states that "cutaneous, decubitus, and stasis ulcers" are non-covered 
for hyperbaric oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on May 9, 2023. 
 
You asked the Plan to pay for initial hospital care (99223). You say that this visit has been coded correctly and 
the attached medical records indicate why procedure code 99223 is appropriate. The Plan denied your request. 
The Plan says the medical records do not support a high level of medical decision making or the total time 
required. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported. Our reviewer found the documentation supports an appropriate exam, 
but not an appropriate history or a high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on May 9, 2023.