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

 
We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that in your opinion, you deem that it is medically 
necessary for the enrollee to receive a Zilretta injection. You also say that due to the enrollee's previous history 
of elevated blood glucose levels following steroid injections, an extended-release corticosteroid is preferred. 
The Plan denied your request. The Plan says Zilretta will not be covered for repeat administration to the same 
knee as the safety and efficacy of repeat administration has not been demonstrated. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of osteoarthritis of the knee. The requested drug is being used for its current 
Food and Drug labelled indication. The FDA has not restricted its use to a single time. Our reviewer found that 
the records provided do not document the observed efficacy from the first injection of the requested drug. The 
provided records are insufficient to establish the medical necessity of the requested service at this time. Our 
physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta (J3304).
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 to go to rehab and that you keep falling. 
You also include that you are blind in one eye and that the providers want you to go to rehab to make him more 
stable. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on February 3, 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 services are included in the inpatient facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that patient transportation from one hospital or SNF 
to another is included in the inpatient payment. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are an ambulance transport 
from one hospital to another while the enrollee was inpatient. Payment for these services is included in the inpatient hospital payment. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 8, 2023, to 
March 24, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe you sent in the NOA timely. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 8, 2022. The NOA was not received by the Plan until April 17, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 8, 2023, to March 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services (90837).  
 
You asked the Plan to pre-approve outpatient mental health services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services 
(90837).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Nivolumab. Our reviewer says that 
Nivolumab is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of stage IV Hodgkin lymphoma. The requested drug is being administered as first line therapy. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition  The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing of autonomic nervous system function (95923) 
provided on January 31, 2023. 
 
You asked the Plan to pay for the testing of autonomic nervous system function. You say that the medical 
records submitted supports code 95923 and should be paid. The Plan denied your request. The Plan says CPT 
code 95923 (1 unit) remains not supported. The submitted medical records do not include documentation to 
support that testing of autonomic nervous system function; sudomotor, including 1 or more of the following: 
quantitative sudomotor axon reflex test, silastic sweat imprint, thermoregulatory sweat test, and changes in 
sympathetic skin potential was performed. Therefore, the billed (CPT) code cannot be 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 95923 is testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. 
 
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 testing of autonomic nervous system function. Our reviewer 
says that CPT Code 95923 is not supported by the documentation submitted. Our reviewer found 
documentation submitted does not meet criteria. For CPT 95923, the provider tests the sudomotor function of 
the autonomic nervous system to check functioning of nerves that supply sweat glands. The autonomic nervous 
system is that part of the nervous system that controls the blood pressure, pulse rate, sweating, and many other 
bodily functions. This procedure was not documented in the medical record and therefore, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing of autonomic nervous system function have not been met. Therefore, we 
decided that the Plan does not have to pay for testing of autonomic nervous system function (95923) provided 
on January 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the enrollee needs to have this injection due to their 
condition. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid 
that are approved by the FDA for the treatment of AD based upon evidence of efficacy from a change in a 
surrogate endpoint considered as reasonably likely to predict clinical benefit may be covered in a randomized 
controlled trial conducted under an IND application.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Leqembi (J0174).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of intrauterine device (IUD) (58300). 
 
You asked the Plan to pre-approve insertion of an IUD. You say that this is medically necessary. The Plan 
denied your request. The Plan says this service has an "N" status in the Medicare Physician Fee Schedule, 
which means the service cannot be covered when billed to Medicare. 
 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 58300 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 58300 is not covered. Based on this information, we decided that Medicare rules for coverage 
of insertion of intrauterine device (IUD) (58300) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of intrauterine device (IUD) (58300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 14, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the samples were sent to your lab by a 
provider who is out-of-network. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service March 16, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that the services are supported by the records. 
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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92202, 92014, and 92134 billed for date of 
service March 13, 2023.  
 
You asked the Plan to pay for procedure codes 92202, 92014, and 92134. You say that the claim was billed 
correctly and should be paid. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 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 92014 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. The MUE for codes 92202 and 92134 
is 1 and the MAI is 2. You billed 2 units of these codes exceeding the MUE. The claim history shows payment 
was made for these services on March 27, 2023. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 92202, 92014, and 92134 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 92202, 92014, and 92134 billed for date of service March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (K0837) and 
additional items and accessories (codes E0955, E1002, E1012, E1028, E2310, E2361, E2608, and E2621) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. You say that the enrollee has been waiting months now for their chair and you are requesting that 
the Plan overturn their decision on the enrollee's chair. The Plan denied your request. The Plan says the 
requested OON provider is not contracted in the enrollees network. The Plan also says they agree the 
enrollees condition makes the specialty or service medically necessary, however, such service is available in-
network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says the Plan will cover services from either network or out-of-network providers, as long as the services 
are covered benefits and are medically necessary. 
 
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. The enrollee can choose to go out-of-
network using their OON benefit level, but the Plan does not have to approve the service(s) at the in-network 
benefit level Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power 
wheelchair (K0837) and additional items and accessories (codes E0955, E1002, E1012, E1028, E2310, E2361, 
E2608, and E2621) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission. 
 
You asked the Plan to pre-approve an inpatient psychiatric admission. The Plan denied your request. The Plan 
says the records do not show that the coverage criteria have been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient psychiatric admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an inpatient psychiatric admission. Our 
physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as 
they do not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not 
showing any behavioral issues. The enrollee is noted to be cooperative and compliant with treatment while not 
showing any aggressive behaviors. Our reviewer also found that it does not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 an inpatient psychiatric admission. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission.
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. The Plan denied your request. The Plan says the enrollee does not 
have daily skilled nursing or therapist needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services in order to regain 
their maximum level of functioning. 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 IRF admission and services.