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

 
We decided that the Plan does not have to pre-approve electronic brachytherapy for breast intraoperative 
radiation therapy (IORT).  
 
You asked the Plan to pre-approve IORT via electronic brachytherapy. You say that IORT via electronic 
brachytherapy is medically necessary. The Plan denied your request. The Plan says that the National 
Comprehensive Cancer Network (NCCN) has not recommended IORT as standard treatment for breast cancer. 
The available scientific evidence does not support conclusions regarding safety, effectiveness, and net 
outcomes. 
 
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 IORT via electronic brachytherapy. Our 
reviewer says that the requested IORT via electronic brachytherapy is not considered medically reasonable and necessary in this case. Our physician reviewer found that that there are many ways to deliver breast radiation, 
either as a sole modality or as a boost; for partial breast or boost radiation, these approaches include LINAC 
based, interstitial brachytherapy catheters, Mammosite balloon, IORT with a portable LINAC and electronic 
brachytherapy. The available scientific evidence does not support conclusions regarding safety, effectiveness, 
and net outcomes for IORT via electronic brachytherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IORT via electronic brachytherapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve electronic brachytherapy for breast intraoperative radiation therapy 
(IORT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve a Sprint PNS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Sprint PNS system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are only case reports supporting this approach. Therefore, the request is deemed 
not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) system (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99291) provided on March 26, 2023. 
 
You asked the Plan to pay for the services. 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 44603 
provided on March 26, 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 the services (99291) provided on 
March 26, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not recommended for prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor 
investigational. HIFU was Food and Drug Administration (FDA) approved for prostate gland ablation on 
October 9, 2015. HIFU of the prostate has Medicare coverage as of July 1, 2017. The Local Coverage 
Determination (LCD) requiring prior radiation treatment was retired by Medicare on 10/20/22. More than 100 
clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much 
lower risk of side effects such as impotence, urinary incontinence, and bowel injury. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve high intensity focused ultrasound (HIFU).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the procedure is covered by Medicare 
and is listed as a covered treatment for knee pain. The Plan denied your request. The Plan says the procedure is 
considered experimental or investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 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 radiofrequency 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have lumbar spine disease.  
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 neck pain with radiation to her arms clearly documented, but the request is 
for diagnostic lumbar medial branch blocks. She had cervical diagnostic medial branch blocks which initially 
provided 70% pain relief. In a later note, it is described as 50% with another 20-30% provided by medications. 
She has had physical therapy and Toradol for pain. There is no role for a series of injections. Each injection 
must be evaluated for degree and duration of pain relief. The documentation of the lumbar spine physical exam 
is not present. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a medial branch block.
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 your current condition requires an IRF level of care. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for an IRF admission to 
be approved.  
 
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 or occupational therapy, there is no documented need for intensive rehabilitation services. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Keytruda. 
 
You asked the Plan to pre-approve Yervoy and Keytruda. You say that the requested drug is medically 
necessary in treating malignant neoplasm of unspecified part of right bronchus or lung. The Plan denied your 
request. The Plan says there is no documentation to support the indication that Keytruda can be used in 
combination with Yervoy. 
 
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 Yervoy and Keytruda. Our reviewer 
says that the requested drugs do not meet the criteria necessary for approval. Our physician reviewer found the 
enrollee had early-stage non-small cell lung cancer in 2019 that was treated with radiation. The enrollee has a 
local regional recurrence and is not a surgical candidate. The enrollee has a PDL1 of 90%, with a plan for a 
combination of Ipilimumam (Yervoy) and Pembrolizumab (Keytruda). The requested combination is not FDA-
approved for the enrollee's diagnosis. The approved combination is with Nivolumab (Opdivo). The requested 
combination is not supported by one of the major drug compendia, or by any clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Keytruda have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Keytruda.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says that the request is 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee's continued need for inpatient level of care will be better met at a LTACH, 
which will likely meet or exceed 25 additional days of his current care level. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology care to be provided by an out-of-
network (OON) provider at the in-network benefit level.  
 
You asked the Plan to pre-approve specialty care. You say that this facility could help the enrollee. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated 
within the Plan network. The Plan says that the enrollee may choose to utilize this provider at the out-of-
network benefit level. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to use out-of-network providers, but the share of costs for covered items 
and services may be higher.   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. The enrollee may choose to see this 
provider using the Plans out-of-network benefits. Therefore, we decided that the Plan does not have to pre-
approve radiation oncology care to be provided by an out-of-network (OON) provider at the in-network benefit 
level.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 32 units of Xiaflex. 
 
You asked the Plan to pre-approve an additional 32 units of Xiaflex. You say that the requested drug and 
dosage is medically necessary. The Plan denied your request. The Plan says the dosage requested is more than 
the allowed amount. 
 
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 Xiaflex (32 units). Our reviewer says 
that the requested drug dosage does not meet the criteria necessary for approval. Our physician reviewer found 
the usual adult dosage of Xiaflex for Dupuytren's Contracture is 0.58 mg (58 units) injected into a palpable 
cord with a contracture of a metacarpophalangeal joint or a proximal interphalangeal joint. The review has 
determined that the requested use of an additional 32 units of Xiaflex is not FDA-approved for the enrollees 
diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal (see appendix for list of CMS-approved journals). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xiaflex (32 units) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 32 units of Xiaflex.
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 requires IRF services in order to learn 
activities of daily living with their new amputation. The Plan denied your request. The Plan says the request 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 the enrollees 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 pre-approve a Group 3 power wheelchair with single power option 
(tilt) and accessories. 
 
You asked the Plan to pre-approve the Group 3 power wheelchair with single power option. You say that the 
enrollee's condition prohibits their mobility and ability to effectively weight shift. You also say that the power 
tilt system is necessary for weight distribution, pressure, and pain management. The Plan denied your request. 
The Plan says the enrollee does not have a medical need for the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain criteria 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 the Group 3 power wheelchair with 
single power option. Our reviewer says that the requested Group 3 power wheelchair with single power option 
is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee is high risk for skin breakdown, use a catheter intermittently, have spasticity interfering with 
positioning or require an alternative means of managing power drive. Therefore, the reviewer found that the 
requested Group 3 power wheelchair with single power option 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 Group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (tilt) and accessories.
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 need more intensive and aggressive 
rehabilitation to help obtain your previous level of activity. The Plan denied your request. The Plan says the 
IRF services you are requesting do not meet the requirements for approval.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.