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

 
We decided that the Plan does not have to pay for arthroplasty, knee, condyle and plateau; medial AND lateral 
compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447) provided on 
September 21, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. CPT code 27447 remains not 
supported. The submitted medical records indicate that the services were performed by a certified surgical first 
assistant (CSFA). Although skilled, a CSFA is not recognized for payment by CMS. Of note, per 
CMS/Medicare guidelines, the services of surgical technicians and certified surgical first assistant (CSFA) are 
not eligible for separate reimbursement. Therefore, we decided that the Plan does not have to pay for 
arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing 
(total knee arthroplasty) (CPT code 27447) provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC). 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says an evaluation in respiratory therapy can be offered instead. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has a history of asthma and prior COVID-19, and currently has home oxygen. She is requesting a POC because 
the oxygen tubing, presumably from her stationary concentrator, gets tangled and increases her risk for falling. 
It is unclear whether the patient has portable oxygen tanks. The records consist only of an emergency 
department (ED) visit for pharyngitis, during which the SpO2 was 98%, without mention of supplemental 
oxygen. The patient has not been tested during ambulation with an oxygen conserving device.  It is not clear 
from the records that the patient requires oxygen currently. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for treatment of swallowing dysfunction and/or oral function for feeding 
(CPT code 92526) provided from September 21, 2021, through September 30, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services were not billed with the GN modifier. 
 
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 find that CPT code 92526 is supported in the medical record. Specifically, the information we received 
shows the provider resubmitted the claim with the appropriate modifier. Therefore, we decided that the Plan 
has to pay for treatment of swallowing dysfunction and/or oral function for feeding (CPT code 92526) provided 
from September 21, 2021, through September 30, 2021.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 you were admitted for surgical management of colon cancer. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy (97530) provided on October 21, 2021. 
 
You asked the Plan to pay for occupational therapy. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the record shows that the services of an OTA are being 
billed as services incident to an NPP's service. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for occupational therapy (97530) provided on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided on December 28, 
2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as 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. In this case, we have confirmed that code 71045 
is a column II code to column I code 36556. This claim 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 the chest x-ray (CPT code 71045) provided on December 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint injections. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found 
one criterion for facet joint interventions to be considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain is: Moderate to severe chronic neck or low back pain, predominantly axial, that 
causes functional deficit measured on pain or disability scale.  Though the provider indicated the members 
low back pain was chronic, there is no indication it was moderate to severe and caused a functional deficit. In 
addition, there is no indication that the member had at least two prior diagnostic facet joint procedures which 
each provided a consistent minimum of 80% relief of primary pain with the duration of relief being consistent 
with the agent used. And there is no indication the enrollee had a subsequent facet joint procedure at the same 
anatomic site with at least consistent 50% relief for at least three (3) months from the prior therapeutic 
procedure or at least 50% consistent improvement in the ability to perform previously painful movements and 
activities of daily living compared to baseline and using the same scale. The review has determined that the 
enrollee does not meet the LCD criteria for the requested facet joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
treatment. The Plan denied your request. The Plan says this 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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the Food and Drug Administration (FDA), the VertiFlex Superion 
Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or 
cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate degenerative 
lumbar spinal stenosis, with or without grade 1 spondylolisthesis, confirmed by imaging evidence of thickened 
ligament flavum, narrowed lateral recess, and/or central canal or foraminal narrowing.  
 
FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients 
with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate 
spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have 
not been adequately addressed in the medical records. There is imaging evidence of grade 1 anterolisthesis at 
L5-S1 measuring 4mm, with no discussion of spinal instability on flexion/extension films. There is no 
documentation of the enrollees height, weight or body mass index. There is no discussion of scoliosis of the 
lumbar spine, and with no documentation of the Cobb angle. Overall, there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested Vertiflex Superion interspinous device at L4-5 and L5-S1 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 the Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
February 11, 2022. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as 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. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim 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 the abdominal ultrasound (CPT code 76705) provided on 
February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic CGM (CPT code K0553) provided on November 
25, 2021. 
 
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. 
The Plan says the date does not match the date of service billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. The medical records did include 
physician notes, a written order and delivery slip, but the shipping or delivery date does not match the date of 
service billed. Therefore, we decided that the Plan does not have to pay for therapeutic CGM (CPT code 
K0553) provided on November 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150 and 87324) 
provided on January 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services (CPT code 87150 and 87324) provided on January 
6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on July 12, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 the drug testing (CPT code G0483) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on July 
22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services (CPT code 87150) provided on July 22, 2021.
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 this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 60-
year-old male with a diagnosis of blepharospasm. The Plan requires a trial of Xeomin before they will approve 
the requested drug, Botox. In this case, there is no indication that the patient has tried and failed the required 
drug. Based on the medical records provided and the Medicare-approved major drug compendia there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
patient. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on August 6, 2020. 
 You asked the Plan to pay for therapeutic activities. You say that these services were medically necessary and 
were billed correctly The Plan denied your request. The Plan says these services are not supported as 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 find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Certified 
Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on August 
6, 2020.