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

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections (27096), moderate 
sedation services (99152), Fentanyl Citrate injection (J3010), Midazolam Hydrochloride injection (J2250), and 
Triamcinolone Acetonide injection (J3301). 
 
You asked the Plan to pre-approve SI joint injections, moderate sedation services, Fentanyl Citrate injection, 
Midazolam Hydrochloride injection, and Triamcinolone Acetonide injection. The Plan denied your request. 
The Plan says information to determine whether the requested treatment/service is medically necessary has not 
been provided at this time. 
 
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 SI joint injections, moderate sedation 
services, Fentanyl Citrate injection, Midazolam Hydrochloride injection, and Triamcinolone Acetonide 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no 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. Our reviewer found that the documentation does not support that the SI joint injections with 
moderate sedation services are medically reasonable and necessary for you. Our physician reviewer also found 
that the documentation does not support that SI joint injections with moderate sedation services are safe and 
effective for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injections, moderate sedation services, Fentanyl Citrate injection, 
Midazolam Hydrochloride injection, and Triamcinolone Acetonide injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections (27096), moderate sedation 
services (99152), Fentanyl Citrate injection (J3010), Midazolam Hydrochloride injection (J2250), and 
Triamcinolone Acetonide injection (J3301).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the requested acupuncture treatment have not been met.  Specifically, the acupuncture treatment requested in this case is not due to a diagnosis of chronic low back 
pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair and accessories to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair. You say that without this chair the enrollee is at risk 
of mortality and the enrollee's condition will continue to decline. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. The Plan has approved the requested power wheelchair to be provided by an in-network 
provider. 
 
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. The Plan agrees that the enrollee meets the 
Medicare criteria and has approved for the requested Group 2 power wheelchair and components to be provided by an in-network provider. Therefore, we decided that the Plan does not have to pre-approve the 
Group 2 power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
necessary. The Plan denied your request. The Plan says you have exhausted your 2022 transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 51st trip and beyond is not a covered 
benefit. Your 2022 EOC states that you are covered for fifty (50) one-way, non-emergency trips to Plan-approved locations within the Plan service area. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography 
(PET); metabolic evaluation (CPT code 78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the medical records provided do not indicate that the enrollee meets the diagnostic 
criteria of both Alzheimer's disease and frontotemporal dementia and there is no indication that the exam is 
being requested in the context of a clinical trial. 
 
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 PET scan. Our physician reviewer 
found the medical records provided do not indicate that the enrollee meets the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia, and that diagnostic uncertainty remains. There is no 
indication that the examination being requested is planned to be performed within the context of a clinical trial.  
The elements of the coverage criteria are not satisfied. The requested service is not 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the brain imaging, positron emission tomography (PET); metabolic evaluation (CPT code 
78608).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93975. 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 76770 
is a column II code to column I code 93975. 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 procedure code 76770 billed for date of service February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64415 and 76942 billed for date of service 
March 29, 2022. 
 
You asked the Plan to pay for procedure codes 64415 and 76942.. The Plan denied your request. The Plan says 
these codes are not payable 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 64415 
is a column II code to column I code 01638. 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. 
 
We also find that CPT code 76942 is not supported in the medical record. Specifically, this code has a PC/TC 
indicator of 1. As such, when billed with a facility place of services, the professional interpretation must be 
billed with modifier -26 for payment to be considered. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76942. have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64415 and 76942 billed for date of service March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat transforaminal epidural steroid injection. You say that the first 
injection may not have been in the correct area. The Plan denied your request. The Plan says a repeat 
transforaminal epidural steroid injection does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. 
 
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 repeat transforaminal epidural steroid 
injection. Our reviewer says that a repeat transforaminal epidural steroid injection is not medically necessary. 
Our physician reviewer found that in this case, the repeat epidural steroid injection (ESI) requested is denied, in 
that you have not had a previous epidural steroid injection (ESI) three months or longer before a repeat ESI 
with the first injection that had directly and significantly provided improvement of the condition being treated 
by at least 50% of sustained improvement in pain relief and or improvement in function measured from baseline using SAME scale for at least three months. 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 a repeat transforaminal epidural steroid injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that you need pain 
relief, and this should never be denied. The Plan denied your request. The Plan says the use of radiofrequency 
ablation for pain management related to sacroiliitis has not been shown to provide a clear long-term benefit 
over standard treatment for chronic sacroiliac joint pain. 
 
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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that sacral lateral nerve branch blocks or 
ablations/neurotomies for the diagnosis or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of sacroiliac joint pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to lower the coinsurance for a diagnostic test. We decided that the Plan does not 
have to waive the coinsurance for the diagnostic test.  
 
You asked the Plan to waive the coinsurance for a comprehensive electrophysiologic evaluation provided on 
June 3, 2019. You say that you are on a limited income and would like help with this coinsurance. The Plan 
says that this cost sharing was charged correctly. 
 
 We decided that the Plan has to lower the coinsurance for a diagnostic test.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for 
diagnostic tests provided in an outpatient hospital.  
 
The Plan says you must pay $4,614.68 of the allowed amount of $22,704.23, or 20.3%, for a comprehensive 
electrophysiologic evaluation. Based on the Plan contract, however, you cannot be asked to pay more than a 
20% coinsurance for diagnostic tests provided in an outpatient hospital. The correct coinsurance for the 
allowed amount is $4,540.85 ($22,704.23 x 20% = $4,540.85).   
 
Therefore, we decided that the Plan has to lower the coinsurance for a comprehensive electrophysiologic 
evaluation provided on June 3, 2019.  
 
We also decided that the Plan does not have to waive the coinsurance amount for a comprehensive 
electrophysiologic evaluation 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance allowed amount for diagnostic tests provided in an outpatient hospital. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a comprehensive electrophysiologic evaluation provided on 
June 3, 2019. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 6 additional physical therapy sessions provided by a 
participating provider. 
 
You asked the Plan to waive the physical therapy. You say that you need all of these sessions. The Plan denied 
your request. The Plan says the services requested are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  
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 waive the physical therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the services needed can be provided in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to waive the 6 additional physical therapy sessions provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show this is safe 
and effective. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee will benefit from additional therapy. 
The Plan denied your request. The Plan says the requested therapy is not medical necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that additional visits are not medically necessary or reasonable based 
on the review of documentation by the physical therapist.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 16 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty (25447) provided on February 1, 2022. 
 
You asked the Plan to pay for the arthroplasty (25447). You say that the operative report details the services 
and should provide proof of necessity. You say that the services were medically necessary, and you should be 
reimbursed accordingly. The Plan denied your request. The Plan says the services of surgical technicians are 
not eligible for separate reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty (25447) provided on 
February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 11, 2021, billed with 
codes 81439, 81286, 81410, 81411, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this claim was not billed 
in accordance with Medicare guidelines and is not covered when provided for screening purposes. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 11, 2021, billed with codes 81439, 81286, 81410, 81411, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 15, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 15, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U 
and 0033U.