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

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found genicular nerve blocks are considered 
experimental therapy and are the subject of ongoing clinical trials. The services are therefore not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested genicular nerve ablation 
is considered experimental/investigational in nature. The services are therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for April 13, 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 procedure code 99223 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 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 these services. Our reviewer says that procedure code 99223 is not supported. Our reviewer found the enrollee presented with altered mental status and respiratory failure. 
He was found to have COVID-19 infection and obstructive uropathy. The records support that an appropriate 
examination was performed by not an appropriate history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on August 25, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this Plan is the primary insurance carrier. 
The Plan denied your request. The Plan says it was determined that another insurance plan is the primary 
insurance carrier. Payment will be reconsidered whenever the explanation of benefits (EOB) is provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has notified the 
provider that an EOB from the primary carrier is required. As the secondary insurer, the Plan cannot be held 
responsible for the anesthesia services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for anesthesia services provided on August 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency destruction of cervical, thoracic, or 
lumbar paravertebral facet joint (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency destruction. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met.  
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than 2 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 of cervical, thoracic, or lumbar 
paravertebral facet joint. Our reviewer says that the services are not medically necessary Our physician 
reviewer found this request exceeds the utilization limit and therefore, it 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 of cervical, thoracic, or lumbar paravertebral facet joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (64635, 64636).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for prolonged office or other outpatient evaluation and management 
services provided on May 9, 2023. 
 
You asked the Plan to pay for prolonged office or other outpatient evaluation and management services. The 
Plan denied your request. The Plan says that these services are a non-covered benefit with the health Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Plan rule or a coding rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for prolonged office or other outpatient 
evaluation and management services provided on May 9, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the enrollee would benefit from this 
procedure with their back pain. The Plan denied your request. The Plan says this procedure is considered 
experimental. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental, and 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee did not achieve at least 50 
percent pain relief for three months from the previous ESI. The criteria for coverage are not met and the repeat 
ESI is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service October 17, 
2022, to October 18, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that you disagree with the denial. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service October 17, 2022, to October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 20, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is urinalysis 
with urine culture and sensitivity. 
 
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 urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no clinical documentation from the time of the ordering of this PCR testing to 
verify the need. Regardless, there was no reported explanation as to why the standard of care was not utilized 
for this enrollee. PCR is not sufficiently supported by high quality studies showing improvement in outcomes 
over standard testing methods to support this request. Therefore, the urine PCR testing will be considered not 
medically 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on June 20, 2023.
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 you need more care. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 
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 you had surgery for a left hip fracture. You received physical and occupational 
therapy in the hospital. You need assistance with functional mobility, including walking to 25 feet. You need 
varied levels of assistance for activities of daily living. You do not require skilled nursing services on a daily 
basis. You do not require skilled therapy on a daily basis. As a practical matter, you do not require the 
necessary services on an inpatient basis at the SNF 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. 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 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. 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 nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is now stable and ready for 
transfer to an LTACH. The appellant says the enrollee meets all criteria for LTACH admission.  The Plan 
denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted for scheduled neck dissection and hemiglossectomy with 
tracheostomy placement and Bjork flap in the setting of head and neck cancer. The record indicates that the enrollee is has ongoing acute medical issues and still requires acute care services.  The enrollee continues to 
receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF services because the current services 
have failed.  The Plan denied your request. The Plan says a SNF admission is not medically necessary.   
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you do not stock Venofer due to patients having 
severe reactions to the drug, and you are unable to obtain Infed due to your distributor having none in stock.  
The Plan denied your request. The Plan says there is no record that shows the enrollee has tried one of the 
preferred drugs, Ferrlecit, Infed, or Venofer, and it has not worked, or that the enrollee has medical reasons that 
prevent them from using one of them.  
 
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 Feraheme. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the records do not contain 
documentation of trial and failure of Ferrlecit, Infed, or Venofer. The records do not support that Ferrlecit, 
Infed, or Venofer would likely be less effective, and/or would 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 the enrollee has known heart failure and this drug 
has been approved in that setting to also reduce admission due to anemia. You say that the physician does not 
feel safe administering the preferred drugs because of the enrollee's condition. 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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the enrollee has an iron deficiency, 
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 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.