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

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that the requested procedure is required 
to necessary to treat your pain. The Plan denied your request. The Plan says the requested procedure does not 
meet the requirements for approval. 
 
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 ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have bilateral knee pain due to osteoarthritis. You had steroid injection 
which did not help your pain. This is considered experimental/ investigational therapy for chronic knee pain 
due to osteoarthritis. 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 ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for discography, each level; 
lumbar. 
 
You asked the Plan to pre-approve an injection procedure for discography, each level; lumbar. You say that an 
injection procedure for discography, each level; lumbar is medically necessary. The Plan denied your request. 
The Plan says the requested injection procedure for discography, each level; lumbar 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 an injection procedure for discography, 
each level; lumbar. Our reviewer says that the requested injection procedure for discography, each level; 
lumbar is not considered medically reasonable and necessary. Our physician reviewer found this is 
experimental therapy. 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 an injection procedure for discography, each level; lumbar have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an injection procedure for discography, each 
level; lumbar.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the requested use of this drug is not indicated for the 
enrollee's condition. 
 
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 Retacrit. Our reviewer says that the 
requested use of Retacrit is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of anemia of chemotherapy for adenocarcinoma of the pancreas. The Food and Drug 
Administration (FDA) has stated that the requested drug is indicated for the enrollee's condition. The record 
provided does not document that the enrollee is continuing to receive chemotherapy and indicates that the 
enrollee is iron deficient. Therefore, the reviewer found that the requested drug, Retacrit, 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (aflibercept, J0178). 
 You asked the Plan to pre-approve Eylea. You say that this drug is necessary, as Avastin is considered off-label 
for the enrollee's condition. The Plan denied your request. The Plan says this drug is not necessary, as the 
enrollee has not had a trial and failure of Avastin. 
 
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 Eylea. Our reviewer says that the Plan's 
coverage criteria are not met in this case. Our physician reviewer found the record indicates that the enrollee 
has diabetic proliferative retinopathy with macular edema. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied; 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (aflibercept, J0178).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the request is medically necessary. The Plan denied 
your request. The Plan says the use of this drug is not medically necessary. 
 
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 Botox. Our reviewer says that the 
requested use of Botox is not supported. Our physician reviewer found the enrollee has a diagnosis of 
gastroparesis. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The noted diagnosis is not one for which coverage is 
available for the requested service. The elements of the coverage criteria 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 billed for date of service May 21, 2023. 
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the 
documentation. 
 
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 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 99223. Our reviewer says that 99223 is not 
supported in the documentation. Our reviewer found that despite containing ample imported and templated 
information, the information is disorganized. Historic details are present, but not presented in a cohesive 
narrative. The physical examination is cursory. While the enrollee appears to be receiving an overall high level 
of care (Intensive Care Unit and tube feeds), a high level of medical decision making is not documented for this 
encounter.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99223 billed for date of service May 21, 
2023.
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 services are medically necessary for 
the enrollee' s complex medical needs. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current setting. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: 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 services are medically necessary for 
the enrollee to receive the care needed for their complex medical condition. The Plan denied your request. The 
Plan says the enrollee's records do not show that their condition will require an average 25-day length of stay in 
the 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 does not require medical care services that they are not currently 
receiving but that would be available in a LTACH setting. The enrollee's needs do not meet the criteria for 
admission to an LTACH. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve entecavir tablets. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve entecavir tablets.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 25, 2023, to August 
1, 2023.  
 
You asked the Plan to pay for the home health services. You say that you have provided medical records to 
show the medical necessity of these services. The Plan denied your request. The Plan says you billed this claim 
with an incorrect Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
Based on this rule, you should have billed this claim with Type of Bill code 0329.  Instead, you billed this 
claim with code 0323, which is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 25, 2023, to August 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee will benefit from the requested 
drug. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 continuation of skilled care is medically necessary 
for the enrollee to receive wound care and skilled therapy. The Plan denied your request. The Plan says the 
enrollee's needs are not medical. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint innervating radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac joint innervating radiofrequency ablation. You say that sacroiliac 
joint innervating radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says 
sacroiliac joint innervating radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve sacroiliac joint innervating radiofrequency ablation. Our reviewer says that the requested sacroiliac joint innervating radiofrequency 
ablation is not considered medically reasonable and necessary. Our physician reviewer found that this is 
considered experimental therapy because of the wide variation in efficacy reported in the peer reviewed 
literature. 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 sacroiliac joint innervating radiofrequency ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint innervating radiofrequency 
ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging/wireless capsule 
endoscopy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the results of a esophagogastroduodenoscopy (EGD or 
colonoscopy in the past 12 months that failed to reveal a source of bleeding or failed to confirm a diagnosis of 
Crohn's disease. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has history of heart failure, fatty liver, who is being referred for wireless capsule 
endoscopy for abdominal pain. The documentation does not support that the enrollee has any indications that 
meet criteria for coverage of this request. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve gastrointestinal tract imaging/wireless capsule endoscopy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31500, 36556 and 76937 billed for date of 
service March 7, 2023. 
 
You asked the Plan to pay for procedure codes 31500, 36556 and 76937. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
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 31500 is intubation, endotracheal, emergency procedure. 
The CPT code manual definition of code 36556 is insertion of non-tunneled centrally inserted central venous 
catheter; age 5 years or older. The CPT code manual definition of code 76937 is ultrasound guidance for 
vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and 
reporting (List separately in addition to code for primary procedure). 
 
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 procedure codes 31500, 36556 and 76937. Our reviewer says 
that these codes are not supported in the medical records provided. Our reviewer found that the documentation 
submitted mentions the intubation and central line placement; however, there is no procedure note from the 
provider that performed these procedures. There is also no procedure note mentioning ultrasound guidance for 
vascular access. It cannot be verified that these procedures were performed as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 31500, 36556 and 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 31500, 36556 and 76937 billed for date of 
service March 7, 2023.