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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical, 
thoracic, and lumbar spine; without contrast (72131, 72125, 72128). 
 
You asked the Plan to pre-approve a CT scan of the cervical, thoracic, and lumbar spine. You say that the 
enrollee has been suffering with cervical pain, back pain and right arm radiculopathy. The enrollee has an 
underlying condition of human immunodeficiency virus, she had necrosis on left shoulder and had surgery on 
July 14, 2020. Further delaying her imaging to try provider directed treatment may be detrimental to her health. 
The Plan denied your request. The Plan says there is no physical examination of the enrollee's back. There are 
no diagnosis of any back/neck problems. The provider states the enrollee has 0/10 pain. The CT scan cannot be 
approved because of the lack of clinical information from the provider showing why the imaging is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan of the cervical, thoracic, and 
lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
according to Medicare, a CT scan is medically necessary if there is literature to support its use for the 
enrollees condition and the scan is reasonable and necessary for the enrollee. In this case, there is no 
documentation of abnormal x-ray findings of the spine that would require advanced imaging or any failure of 
conservative care including a home exercise program or physical therapy. The physical exam is documented as 
unremarkable and there was no acute pain. The documentation doesn't support the need for advanced imaging 
with CT scan for the cervical, thoracic and lumbar spine. 
 
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 CT scan of the cervical, thoracic, and lumbar spine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
cervical, thoracic, and lumbar spine; without contrast (72131, 72125, 72128).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36901, 36904, 37246 and 37248 billed for 
date of service April 6, 2022. 
 You asked the Plan to pay for procedure codes 36901, 36904, 37246 and 37248. You say that the services at 
issue have been billed correctly. The Plan denied your request. The Plan says the services at issue are not 
supported in the medical records. 
 
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 36901 is: Introduction of needle(s) and/or catheter(s), 
dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter 
placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery 
through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological 
supervision and interpretation and image documentation and report; of code 37246 is Transluminal balloon 
angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same artery; initial artery; and of code 37248 is Transluminal 
balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological 
supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein. 
 
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 36901, 37246 and 37248. Our reviewer says 
that procedure codes 36901, 37246 and 37248 do not meet criteria for payment. Our reviewer found that the 
procedure codes at issue cannot be verified in the operative report. 
 
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 36901, 37246 and 37248 have not been met. 
 
Furthermore, in this case, we have confirmed that code 36904 is a column II code to column I code 37246. This 
claim line has not been billed with an appropriate modifier to bypass the edit. 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 codes 36901, 36904, 37246 and 37248 billed for date of service April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the follow up office visit to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network service. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there is an in-network provider that can perform the services you 
need. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the follow up office visit to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve photodynamic therapy (96920, 96921, 96922). 
 
You asked the Plan to pre-approve the physician services. You say that the plan used the wrong medical policy. 
You say that excimer laser treatment is medically necessary. You also say that the enrollee has met the 
requirement of having tried and failed conservative treatment. The Plan denied your request. The Plan says that 
the requested treatment is not medically 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the physician services. Our reviewer 
says that the requested photodynamic therapy is considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested treatment is considered the standard of care for the enrollee's 
condition. Therefore, the requested treatment is 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 the physician services have been met. Therefore, we decided that the Plan has to 
pre-approve photodynamic therapy (96920, 96921, 96922).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried zoledronic acid or have a history of osteoporosis related fracture. 
 
 
 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 Prolia. Our physician reviewer found 
that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new 
start. The Plan requires a trial of zoledronic acid or a history of osteoporosis related fracture before they will 
approve the requested drug. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The 
Plan denied your request. The Plan says the requested Retacrit 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 Retacrit. Our reviewer says that the 
requested Retacrit is not medically necessary. Our physician reviewer found the requested use of Retacrit is not 
FDA-approved for the enrollee's diagnosis. The enrollee will need iron repleted prior to see if qualifies. The 
requested use of Retacrit is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medically appropriate level of care 
for the enrollee is an LTACH admission. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided records and the lab report to 
support payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 20, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code(s) 99153, 75774, 75716 and 76937 billed for date of 
service June 15, 2022. 
 
You asked the Plan to pay for procedure code(s) 99153, 75774, 75716 and 76937. You say that these services 
were reported correctly and are supported in the medical record. The Plan denied your request. The Plan says 
that these codes are included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components are payable when the enrollee is not a patient of any hospital, and the service is received 
in a setting that is not part of a hospital. 
 
The Plan has not submitted evidence that indicates this service was provided to the enrollee while an inpatient 
or outpatient in any hospital. This claim was billed with place of service code 11 (office), which is defined as a 
non-hospital setting. In this case, CPT codes 75774, 75716 and 76937 do not need to be billed with a modifier 
to indicate the professional component only. In addition, it would be appropriate to bill code 99153, as 
technical services are payable in this case. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99153, 75774, 75716 and 76937 have been met. Therefore, we decided that the 
Plan has to pay for procedure code(s) 99153, 75774, 75716 and 76937 billed for date of service June 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty spinal surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there are no imaging studies in the 
submitted documentation showing that you have an acute fracture with buildup of bone marrow (bone marrow 
edema). The criteria for coverage are not met; therefore, the kyphoplasty is not reasonable or medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty spinal surgery.
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. The Plan denied your request. The Plan says the enrollee does not 
require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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. 
 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 the domiciliary visit (99336) provided on July 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the provider is currently 
overseeing the enrollee for various medical conditions. You also say that the services are rendered to the 
enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit (99336) provided on July 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation. 
 
You asked the Plan to pre-approve neuroablation. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain 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 neuroablation. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this is considered an experimental, 
investigational procedure. 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 neuroablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagram Intravenous immunoglobulins (IVIG) 
(A4221, E0781, A4222, G0068) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Octagram IVIG to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Octagram Intravenous immunoglobulins (IVIG) (A4221, E0781, A4222, G0068) 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is very complex, and a 
skilled nursing facility level of care cannot provide the high level of care the enrollee's needs. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can safely 
receive the care they need in the current hospital 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 that the enrollee is improving and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until more appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.