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

 
We decided that the Plan does not have to pre-approve diaphragm pacing and stimulation with neurostimulator 
implantation. 
 
You asked the Plan to pre-approve diaphragm pacing and stimulation with neurostimulator implantation. You 
say that the records provided support the need for the requested procedure. The Plan denied your request. The 
Plan says the clinical value and effectiveness of the requested service has not been demonstrated in peer-
reviewed literature in the setting of progressing pulmonary fibrosis prior to a possible lung transplant. 
 
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 diaphragm pacing and stimulation with 
neurostimulator implantation. Our reviewer says that diaphragm pacing and stimulation with neurostimulator 
implantation is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the record indicates that the enrollee has rapidly progressing idiopathic pulmonary fibrosis and may require 
lung transplantation.  The record indicates that the enrollee has phrenic nerve dysfunction.  There is insufficient 
literature to support the safety and efficacy, as defined by Medicare rules, of the requested service in the 
enrollee's specific clinical scenario.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diaphragm pacing and stimulation with neurostimulator implantation have not 
been met. Therefore, we decided that the Plan does not have to pre-approve diaphragm pacing and stimulation 
with neurostimulator implantation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest, abdomen 
and pelvis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says weight loss alone is not an adequate indication for this. 
 
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 the services. Our reviewer says that the 
requested scans are not medically reasonable or necessary. Our physician reviewer found in terms of the CT 
scan of the chest, you have a smoking history, so you qualify for a yearly low dose CT scan, which is a more 
appropriate service for you in this case. In terms of the abdomen and pelvis, there is no lab work indicative or a 
need for computed tomography of the abdomen and pelvis. Likewise, there are no reports from the ultrasound 
of the abdomen and pelvis in the records. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) scan of the chest, abdomen and pelvis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited abdominal ultrasound (76705) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 limited abdominal ultrasound (76705) provided on December 
9, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy (90834) provided on October 13, 2021. 
 
You asked the Plan to pay for the psychotherapy (90834). The Plan denied your request. The Plan says that the 
provider must attempt to consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy (90834) have been met. Specifically, the record shows that the enrollee was 
referred to this provider by a primary physician. Therefore, we decided that the Plan has to pay for 
psychotherapy (90834) provided on October 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inspan stabilization device. 
 
You asked the Plan to pre-approve the Inspan stabilization device. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/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 the Inspan stabilization device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do 
not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition as discussed above. The specific level of implantation is not evident in the 
documentation provided for review. 
 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 Inspan stabilization device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Inspan stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction provided on June 14, 2021. 
 
You asked the Plan to pay for mechanical traction. The Plan denied your request. The Plan says the services 
rendered not Medicare covered benefit. Chiropractors are unable to bill any codes outside of manipulation 
codes. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and Medicare rules. The only chiropractic service Medicare covers is manual 
manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does not have to pay for 
mechanical traction provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (93306). 
 
You asked the Plan to pre-approve transthoracic echocardiography. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not indicated for the enrollee at this time.  
The Plan follows Medicare rules. Medicare rules say that Transthoracic Echocardiograms are covered for 
limited indications as described in the 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 transthoracic echocardiography. Our 
reviewer says that the requirements for coverage of transthoracic echocardiography have not been met. Our 
physician reviewer found the records do not show clinical evidence of a cardiac abnormality. The medical 
necessity of transthoracic echocardiography in this this patient's clinical management is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transthoracic echocardiography (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95861) and somatosensory 
testing (95927 and 95938) provided on August 25, 2021. 
 
  You asked the Plan to pay for the needle electromyography (95861) and somatosensory testing (95927 and 
95938). You say that the facility has not paid you and you do not have a contract to get paid by them. You say 
that the CPT codes and modifier billed are subject to separate payment. The Plan denied your request. The Plan 
says payment of this claim has not been met as the professional interpretation of a diagnostic test must be 
separately billed with modifier 26. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. The CPT Code Manual definition of code 95927 short-latency somatosensory 
evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous 
system; in the trunk or head. The CPT Code Manual definition of code 95938 short-latency somatosensory 
evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous 
system; in upper and lower limbs  
 
We find that CPT codes 95861, 95927 and 95938 are not supported in the medical record. Specifically, CPT 
codes 95861, 95927 and 95938 are TC only codes and the claim indicates that the services were rendered in a 
facility setting. Payment for CPT codes 95861, 95927 and 95938 is made to the facility and is the responsibility 
of the facility to any physician or vendor. Based on this information, we decided that Medicare rules for 
coverage of the needle electromyography (95861) and somatosensory testing (95927 and 95938) have not been 
met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95861) and 
somatosensory testing (95927 and 95938) provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
You asked the Plan to pre-approve Praluent. You say that you have been tolerating this drug very well. You say 
that this medication is very important and that you have been seeing amazing results on your lab levels since 
taking it. You say that the requested drug is decreasing the possibility for an event in the future. The Plan 
denied your request. The Plan says you did not elect to enroll in a prescription drug plan with them. The Plan 
says that your contract is a medical plan only. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent.   
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of drug an oral bisphosphonate and zoldronic acid before they will approve the requested drug. The records do 
not indicate that the enrollee has tried these drugs. The documentation does not support that an oral 
bisphosphonate and zoldronic acid would likely be less effective or have adverse effects for the enrollee in this 
case. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the adjacent tissue transfer (14060), provided on September 14, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer. You say that the service should be covered. The Plan 
denied your request. The Plan says that no prior authorization was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan's must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the adjacent tissue transfer have been met. Therefore, we decided that the Plan has to pay for the 
adjacent tissue transfer (14060), provided on September 14, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and your lungs were clear. You do not require skilled nursing or therapy services on a daily basis. You do 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on August 23, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
these services were medically necessary and rendered in good faith. The Plan denied your request. The Plan 
says there is no documentation of a consultation with the member's primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90832) provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient knee arthroscopy with platelet-rich plasma 
injection for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows platelet rich plasma 
injections to be an effective and/or safe treatment for patients undergoing meniscal repair. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested outpatient right knee arthroscopy (0232T-platelet rich plasma 
injection), 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an outpatient knee arthroscopy with platelet-rich plasma injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for lumbar 
spinal stenosis with neurogenic claudication and chronic pain syndrome. Current evidence based medical 
guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition as discussed above. The Vertiflex 
spacer is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93229). 
 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry. You say that your doctor is 
requesting the procedure and you trust your doctor to only request things if it is medically necessary. The Plan 
denied your request. The Plan says the requested services are not reasonable and necessary. 
 
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 external mobile cardiovascular 
telemetry. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has frequent, daily palpitations. There is no 
supportive evidence that the ordering practitioner documented any standard, non-MCOT, ambulatory ECG 
monitoring. In summary, there is insufficient documentation to support the medical necessity for an MCOT 
monitor in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93229).