Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a High Intensity Focused Ultrasound (HIFU) of the prostate 
(55880). 
 
You asked the Plan to pre-approve a HIFU. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service 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 a HIFU. Our reviewer says that the 
requested service is considered medically reasonable and necessary 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 a HIFU have not been met. Therefore, we decided that the Plan has to pre-
approve a High Intensity Focused Ultrasound (HIFU) of the prostate (55880).  
 
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 an intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 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 cause of back pain is unclear. 
 
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 (64628 and 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like the Plan to figure this out. The 
Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology services to be provided at the in-
network benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve gastroenterology services. You say that you think you are doing good by 
seeing this provider to combine all of the procedures you need. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan and you can receive care within the Plan network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you may choose to utilize out-of-network providers with the Plans POS benefit. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. The Plan says that you may see this 
provider using the Plans POS benefit. Therefore, we decided that the Plan does not have to pre-approve 
gastroenterology services to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac joint radiofrequency ablation (64625) 
with sedation (01992). 
 
You asked the Plan to pre-approve bilateral sacroiliac joint radiofrequency ablation with sedation. You say that 
the services are medically necessary. The Plan denied your request. The Plan says this is considered 
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 bilateral sacroiliac joint radiofrequency 
ablation with sedation. Our reviewer says that the requested are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral sacroiliac joint radiofrequency ablation with sedation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac joint radiofrequency 
ablation (64625) with sedation (01992).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that this benefit came with the package of the 
Plan, you have seen the provider once, and were able to use the benefit last year. You also say that you did not 
receive any notification about the benefit change, and have not seen the provider this year. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service April 16, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem.   
 
 We find that CPT code 99233 is not supported in the medical record. Specifically, the records do not document 
a detailed interval history or decision making of high complexity. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for date of service April 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from a short stay at an 
inpatient rehabilitation facility to regain their independence to return home safely. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at a 
lower level of care. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 12002 provided on September 2, 
2022. 
 
You asked the Plan to pay for procedure codes 99285 and 12002. You say that you would like the Plan to 
reconsider their denial of payment. 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 providers and suppliers that render services or 
items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for claims. 
 
We looked at the file and Medicare rules. Medicare rules say that providers and suppliers that render services 
or items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for claims. The Plan will accept a corrected claim for review. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99285 and 12002 provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 37253-59 and 75716-59 provided on September 20, 
2022. 
 
You asked the Plan to pay for 37253-59 and 75716-59. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for these codes is not supported. 
 
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 37253-59 is intravascular ultrasound (noncoronary 
vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 
The CPT Code Manual definition of code 75716-59 is angiography, extremity, bilateral, radiological 
supervision and interpretation.  
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 37253-59 and 75716-59. Our reviewer says that these codes 
do not meet criteria for payment. Our reviewer found according to coding rules, the primary intravenous 
ultrasound includes evaluation of a lesion that extends into multiple vessels. A subsequent vessel intravenous 
ultrasound (37253-59) is not supported as a separately identifiable procedure. The angiography performed on 
the left leg is included int he primary procedure. There is a more appropriate code to report a unilateral 
angiography that is not included in the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37253-59 and 75716-59 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 37253-59 and 75716-59 provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (ESI) (64483, 64484). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 the epidural steroid injections. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the member did not 
have 50% pain relief for three months after previous ESI. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injections (ESI) (64483, 64484).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's needs more rehab to gain their 
maximum level of strength to return home. The Plan denied your request. The Plan says that a SNF admission 
is not medically necessary. 
 
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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has documented skilled nursing and skilled therapy needs in the 
form of twice daily wound and dressing care. The enrollee needs to learn how to mobilize and tend to activities 
of daily living with their injuries and dressings. Therefore, the enrollee qualifies for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal surgery (22558, 22853, 22612, 20930, 20936). 
 
You asked the Plan to pre-approve a spinal surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 a spinal surgery. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a recent 6 week trial and failure of physical therapy (PT) for back 
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 a spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a spinal surgery (22558, 22853, 22612, 20930, 20936).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a a bilateral breast reduction. 
 
You asked the Plan to pre-approve a bilateral breast reduction. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 a bilateral breast reduction. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has had weight loss after bariatric surgery.  
The records provided are insufficient to support medical necessity. 
 
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 bilateral breast reduction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a a bilateral breast reduction.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy and occupational therapy. 
 
You asked the Plan to pre-approve physical therapy and occupational therapy. You say that you would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says 
physical therapy and occupational therapy 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 pre-approve physical therapy and occupational 
therapy services. 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 although you require a 
standard evaluation, there is no evidence that specialty services are required. 
 
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 and occupational therapy services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve physical therapy and occupational therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if the weight loss is the result of bariatric surgery, 
abdominoplasty/panniculectomy should generally not be performed until at least 18 months after bariatric 
surgery and only when weight has been stable for at least the most recent 3 to 6 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 panniculectomy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have had 
massive weight loss after bariatric surgery. The record does not indicate that you have had a stable weight for 
the last three to six months or that you have had intertrigo refractory to conservative treatment. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.