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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plain films show anterior wedging, which could be the result of compression 
fractures, with no indication of an evaluation for osteoporosis. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the magnetic resonance imaging (MRI) does not corroborate Modic changes in the 
requested procedure at L5 and S1. Additionally, there were/are multiple plausible pathologic sources of 
significant pain generation. The non-radiating back pain, the noted pain-aggravating factors (physical activity 
that requires forward flexion), pain-relieving factors (rest and activity modification), and intact neurologic 
exam were/are all non-specific to any pathologic entities. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L5 and S1, in this case, 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
6, 2021, to July 13, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, in the emergency department, the patient was noted to be in moderate distress with faint 
wheezing and an oxygen saturation of 80%. The patient's chest x-ray showed airspace disease suspicious for 
pneumonia. There was no clinical or laboratory evidence of sepsis. The review has determined that  the 
documentation did not support diagnosis code A41.9 - sepsis, unspecified organism. The records support DRG 
155 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 6, 2021, to July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service January 26, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service January 26, 2022, billed 
with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve this item. You say that this item is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item. Our reviewer says that a 
home ventilator is not medically necessary. Our physician reviewer found that this enrollee has chronic 
obstructive pulmonary disease (COPD) and was recently hospitalized with pneumonia. The arterial blood gas 
(ABG) was consistent with acute on chronic hypercarbic respiratory failure. This enrollee may benefit from a 
bilateral airway pressure (BiPAP) machine with average volume assured pressure support (AVAPS) during 
sleep as an outpatient. The records do not show this has been tried and failed.  Medicare does not cover a home ventilator when used as a BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 5, 2022, 
through July 29, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rule for payment of this claim has not been met. 
 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 home health services have not been met. The final claim was 
billed incorrectly without the condition code "54" which is required as there are no skilled home health visits 
billed in this period. The claim does not contain any skilled home health visits (Revenue Code 042X, 043X, 
044X, or 055X), and The From Date is not equal to the Admit Date of HH PPS Claims. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from July 5, 2022, through July 29, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of a permanent cardiac 
contractility modulation system (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart Cardiac Contractility Modulation (CCM) device. You 
say that the device is medically necessary for the enrollee's medical condition. The Plan denied your request. 
The Plan says the Optimizer device is considered unproven. The Plan benefits say unproven and experimental 
procedures and items are those items and procedures not generally accepted by the medical community. 
 
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 Optimizer Smart Cardiac 
Contractility Modulation (CCM) device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found at issue is whether implantation 
of the CCM system in this enrollee is medically necessary for the treatment of CHF which has been deemed 
refractory to optimal medical therapy. An exhaustive review of the current medical literature pertaining to the 
CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several 
randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the 
data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and 
objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject 
of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. At the current time, the CCM system is not medically necessary for this enrollee. 
 
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 Optimizer Smart Cardiac Contractility Modulation (CCM) device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an insertion or replacement of a 
permanent cardiac contractility modulation system (0408T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that 
Retacrit is not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Retacrit at issue in this case 
meets all Medicare criteria for safe and effective for the patient. Provided medical records do not document a 
recent (within the past 4 months) transferrin saturation of at least 20% and ferritin level of at least 100 mcg/L 
as required by the Medicare-approved major drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair.. You say that this wheelchair is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power mobility device that was provided on December 5, 2022. The power 
wheelchair serves the same purpose as the existing power mobility device. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the procedure is medically necessary 
due to the enrollee's pain. The Plan denied your request. The Plan says unproven and not medically necessary 
procedures are not covered by Medicare. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. More info is needed due 
to insufficient evidence of efficacy. 
 
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 a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 11, 2022, to 
February 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that an NOA is on file. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 11, 2022, to 
February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology and other services (procedure code 71250, 74176, 
G0463, G1004) provided to the enrollee on August 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 71250: 
 
Computed tomography, thorax, diagnostic; without contrast material 
 
CPT 74176: 
 
Computed tomography, abdomen and pelvis; without contrast material  
Healthcare Common Procedure Coding System (HCPCS) G0463: 
 
Hospital outpatient clinic visit for assessment and management of a patient 
 
HCPCS G1004: 
 
Clinical decision support mechanism national decision support company, as defined by the Medicare 
appropriate use criteria program 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that G0463 was not reported with 
modifier 25, which is required when billed with other procedures on the same date of service (71250 and 
74176). G1004 is a statistical code that is not reported for reimbursement purposes. 
 
We looked at this coder'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 pay for radiology and other services (procedure code 71250, 74176, G0463, G1004) provided to the 
enrollee on August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 75716. You say that all codes should be paid as billed. The Plan 
denied your request. The Plan says payment for code 75716 is bundled into payment for code 37244.  
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 75716 is a column II code to column I code 37244. Modifier -XU 
was reported with code 75716. Review of the records does not support that 75716 is being used to describe an 
angiography that is distinct from the services included in the vascular embolization or occlusion described by 
code 37244. Based on this information, we find that the Medicare rules for this service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 75716 billed for date of service 
August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 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 safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve this item. You say that the requested item is medically necessary for the 
enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item. Our reviewer says that the 
requested item is not medically necessary. Our physician reviewer found that this enrollee has chronic 
obstructive pulmonary disease (COPD) with repeated hospital admissions. The records do not include 
pulmonary function tests, or arterial blood gas (ABG) testing, done while stable, demonstrating chronic carbon 
dioxide retention.  
 If the enrollee does have chronic carbon dioxide retention, she may benefit from bilevel positive airway 
pressure (BiPAP) with average volume assured pressure support (AVAPS) during sleep as an outpatient. 
Medicare does not cover a home ventilator when used as a BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (E0466).