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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure will improve the 
patient's quality of life. The Plan denied your request. The Plan says the Intracept procedure is not considered 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic endplate changes 
without foraminal stenosis or facet degenerative disc disease. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 system.  
 
You asked the Plan to pre-approve the Life2000 system. You say that the patient requires a home ventilator 
because it provides her the option for a secondary mode for daytime use. The Plan denied your request. The 
Plan says the requested Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. It is designed primarily for use during activity. There is insufficient evidence of benefit in 
the treatment of COPD. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 Life2000 system. Our reviewer says 
that the Life2000 system is not medically necessary. Our physician reviewer found the provided records 
document that the home ventilator is being requested for use with very low set tidal volumes (150 to 230 mL) 
which could be provided by a bilevel positive airway pressure (BiPAP) device with average volume-assured 
pressure support (AVAPS) and a back-up rate. The provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
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 Life2000 system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Life2000 system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hi rise toilet (E1399) provided on June 14, 2022. 
 
You asked the Plan to pay for the hi rise toilet. You say that you would like the Plan to cover the $100 durable 
medical equipment allowance for bathroom safety for your toilet. The Plan denied your request. The Plan says 
the services rendered are not covered by Medicare or your benefit plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also 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. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. There is also 
insufficient information in the record to determine if Medicare rules for coverage of the hi rise toilet have been 
met. Specifically, the receipt/proof of payment you submitted with this case is general, and not itemized to 
show the exact cost of each item. Installation is also clearly excluded according to your 2022 Evidence of 
Coverage. Therefore, we decided that the Plan does not have to pay for the hi rise toilet (E1399) provided on 
June 14, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the 
documentation does support that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee has a diagnosis of osteoarthritis of the knees. The Food and Drug Administration 
has stated that the requested drug is indicated for the enrollee's condition. The elements of the coverage criteria 
are satisfied. Therefore, the enrollee meets criteria for the requested drug. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 13, 2023, to January 18, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not know you 
would get a semi-private room. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan clearly says you then pay a $0 copayment per day for days 6-90 of each in-network inpatient hospital stay. 
 
You have been asked to pay a $325 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day five 
or for the day you were discharged. You have been asked to pay a total of $1,625 ($325 copayment per day x 5 
days = $1,625). This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 13, 2023, to January 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care provided from September 1, 2022, to 
September 21, 2022. You asked the Plan to pay for the billed services. You say that the claim was filed 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 September 1, 2022. The NOA was not received by the Plan until November 
9, 2022. 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 the home health care provided 
from September 1, 2022, to September 21, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane. 
 You asked the Plan to pre-approve Abraxane. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says 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 Abraxane. Our reviewer says that 
Abraxane is not medically necessary. Our physician reviewer found that the enrollee has non-small carcinoma 
of the lung, 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 coverage criteria have not been satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service January 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the diagnosis codes. 
The Plan denied your request. The Plan says that the diagnosis codes were not billed correctly. 
 
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 denied services stating diagnosis codes I60.9 and S06.301A should not be billed together. We looked 
at the file and the rules. The S06 and S06.3 diagnosis groups do not include I60 as an excluded code. Similarly, 
the I60 diagnosis group does not include S06 as an excluded code. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for procedure code 99223 billed for date of service January 16, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT), single area (e.g., head, neck, chest, pelvis), single day 
imaging (78803). 
 
You asked the Plan to pre-approve radioembolization procedure. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 radioembolization procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the appeal is for the denial of SPECT (CPT 78803) as part of a Y-90 
radioembolization (SIRT) procedure. The enrollee has a history of metastatic ovarian cancer (high grade serous 
histology) to liver; there has never been a diagnosis of hepatocellular carcinoma in this case. It is unknown 
when the ovarian cancer diagnosis was first made. The enrollee has been on various systemic therapies. A 
PET/CT a few months ago identified a solitary lesion in the liver. The enrollee seems quite infirm with a very 
low performance status (ECOG 4). The review has determined that the enrollee does not meet criteria for 
approval of the requested procedure. The procedure is 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 radioembolization procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiopharmaceutical localization of tumor, inflammatory process or 
distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 
tomographic (SPECT), single area (e.g., head, neck, chest, pelvis), single day imaging (78803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 
27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen by different specialists. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records show that the enrollee was seen by two cardiologists from the 
same provider group. CPT code 99223 was not billed with a modifier to indicate it was separate and distinct 
from procedure code 93458. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99223 billed for date of service December 27, 2022.
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 will benefit from this level of care to 
increase their level of functioning prior to returning home. 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 does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at 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 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 F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pay for the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant. 
You say that that this testing is medically necessary to develop the most appropriate treatment plan for the 
enrollee. The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant have not been met. 
Therefore, we decided that the Plan does not have to pay for F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. 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 PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 PVA. Our reviewer says that the service 
are not medically necessary. Our physician reviewer found there is no clear documentation of a progression of 
vertebral body height loss, kyphotic deformity, or severe impact of vertebral compression fracture on daily 
functioning. Additionally, the magnetic resonance imaging (MRI) demonstrated stenosis at the requested 
surgical levels. Anterolisthesis has been demonstrated on the MRI without flexion/extension films to rule out 
instability at the L4-L5 levels. Fracture retropulsion is noted with canal compromise at the L4 and L5 
vertebrae. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basiverterbral nerve 
(the Intracept procedure).  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic endplate 
changes without foraminal stenosis or facet joint syndrome. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 a genicular nerve block is medically 
necessary because the member suffers from chronic knee pain due to osteoarthritis and replacement of the left 
knee. The Plan denied your request. The Plan says genicular nerve blocks are not covered to treat osteoarthritis 
as this is considered investigational.  
 
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 genicular nerve block.is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that genicular nerve block is the subject of ongoing clinical trials and is 
considered experimental at this time. 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.