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

 
We decided that the Plan does not have to pre-approve Darzalex FasPro injections. 
 
You asked the Plan to pre-approve Darzalex FasPro injections. You say that the requested drug is necessary. 
The Plan denied your request. The Plan says the requested drug is not supported by current medical literature or 
Medicare approved compendia. 
 
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 Darzalex FasPro injections. Our 
reviewer says that the Darzalex FasPro injections are not medically reasonable and necessary. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of multiple myeloma and is status post stem cell transplant. The requested drug regimen is being prescribed for maintenance therapy. The Food and 
Drug Administration has not stated that the requested drug regimen 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 regimen in the enrollee's clinical situation. No literature from Medicare approved cancer journals was 
submitted for review. The elements of the coverage criteria are not 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 Darzalex FasPro injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Darzalex FasPro injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they do not have other sources of the 
enrollee's back pain. The Plan states the enrollee has spinal stenosis, both central and neuroforaminal. The Plan 
states the enrollee has facet arthopathy with previous response to radiofrequency ablation. The Plan states the 
enrollee has a diagnosis of lumbar radiculopathy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the magnetic resonance imaging (MRI) shows foraminal stenosis and facet degenerative joint 
disease (DJD). The cause of back pain is not clear. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 Health Plans denial should be upheld. You do not require the intensity of 
services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. Your 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 25, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that these services should both be payable. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220. 
 
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, we have confirmed that code 99497 
is a column II code to column I code 99220. It appears that a modifier was appended to the column I code, but 
it is required for the column II code. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99497 billed for date of service 
August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultra-lightweight wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that you cannot walk and urgently need this 
wheelchair. 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 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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the ultra-lightweight 
wheelchair and accessories at issue in this case meet all Medicare criteria for medically reasonable and 
necessary for the enrollee. The provided records in this case do not clearly support that the enrollee is a full-
time manual wheelchair user as required by the Local Coverage Determination (LCD) Manual Wheelchair 
Bases L33788. The provided records from therapy and the device vendor do not document the enrollee is non-
ambulatory and the records from the physician report the enrollee uses a cane, walker and wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ultra-lightweight wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the admission to an IRF 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 review has determined that the complexity of the enrollee's nursing, medical, 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that the enrollee is without evidence on 
imaging study magnetic resonance imaging (MRI) suggesting another obvious cause for the enrollee's low back 
pain. The Plan states the enrollee has evidence of severe facet arthropathy at the level of the requested 
procedure- L3-L4. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the cause of back pain is unclear. The magnetic resonance imaging (MRI) shows facet 
degenerative joint disease (DJD). 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial excision of posterior vertebral component 
(eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar (22102) and 
unlisted procedure, nervous system (64999). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is not enough medical evidence that this type of procedure is effective. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the endoscopic ryzotomy is experimental for back pain. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the partial excision of posterior vertebral component (eg, spinous process, lamina or facet) 
for intrinsic bony lesion, single vertebral segment; lumbar (22102) and unlisted procedure, nervous system 
(64999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac (SI) joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show the enrollee has imaging studies that the 
enrollee's pain is caused by another diagnosis (such as the enrollee's concern about an occult cancer lesion), or 
that the enrollee had positive findings with at least three (3) of the above maneuvers (only one (1) was 
documented in the records sent, SI joint compression). 
 
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 service. Our physician reviewer 
found there is no documentation on physical examination of three (3) or more positive tests results. The clinical 
value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing 
results have not been demonstrated in the peer-reviewed literature. The review has determined that the medical 
records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management services provided 
on October 2, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that this code is supported. The Plan denied 
your request. The Plan says the decision making was not of high complexity. As such, this code 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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 EM services as billed. Our reviewer says 
that the documentation does not support the billed code. Our reviewer found the evaluation and management 
code requires a comprehensive history, a comprehensive examination and medical decision making of high 
complexity. In this case, the medical records submitted do not support a medical decision making of high 
complexity. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital evaluation and management services provided on October 2, 2022, 
billed with code 99223.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) home health skilled nurse visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there is no evidence that the enrollee's condition is fluctuating, and 
no evidence of additional caregiver teaching or medication management needed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation from most recent evaluation does not show any new clinical concerns or medications changes; 
thus, the records do not show that home health skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. Four additional home 
health skilled nursing visits are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four (4) home health skilled nurse visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36620 and 93312 billed for May 4, 2022. 
 
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 codes 36620 and 93312 are 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 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. The definition of code 93312 is 
echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report. 
 
We find that CPT codes 36620 and 93312 are not supported in the medical record. Specifically, the records 
include an arterial catheterization or cannulation for sampling; however, the records show that the services 
were rendered by a provider other than the billing provider. Therefore, code 36620 is not supported. There is no 
documentation of a real-time transesophageal echocardiography with image documentation to support code 
93312. 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 codes 36620 and 93312 billed for 
May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, anterior (D2330) 
provided on January 3, 2023. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this dental item is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite-one surface, anterior (D2330) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) with 9 
fractions (77387, G6002, 77386, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that it is medically necessary. The Plan denied your request. 
The Plan says the enrollee's doctor has requested a greater number of daily treatment doses than is needed. 
Fifteen daily treatment doses are allowed for the enrollee's treatment course. The request for more than 15 
doses exceeds this limit. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a more protracted 6-15-fraction approach would be a standard alternative for enrollees with 
central or ultra-central lung tumors for which SBRT might be associated with unacceptable risks of toxicity. 
This enrollee's tumor is 'ultracentral' for which 8-15 fractions of HIGRT with IMRT are standard. The records 
provide no evidence basis (any trials or published data or guidelines) that would advocate treating metastatic 
disease with conventional fractionation to definitive doses. The reviewer would agree that IMRT would be 
justified in this case, but not in excess of 15 fractions. When opting conventional fractionation, IMRT could be 
considered medically necessary with dosimetric justification as supported by consensus guidelines and 
published literature. For this case, no dosimetric justification is provided and it is not plausible that accepted 
dosimetric constraints could not be met with the treatment of a single isolated central RUL lung nodule. The 
decision is unfavorable as 30 fraction IMRT is not standard of care for an isolated lung metastasis and the 
records provide no basis (guidelines, published data) to justify necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT) with 9 fractions (77387, G6002, 77386, G6015).