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

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. 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 Hyalgan. Our reviewer says that the 
requirements for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a 
trial of any two of Durolane, Euflexxa, Supartz, and GelSYN-3 before they will approve the requested drug. 
Based on the medical records provided, there is no indication that the enrollee has tried and failed the required 
drugs. There is also no indication that the required drugs would likely be less effective or have adverse effects 
for the 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that your doctor said the stress test and 
echocardiogram are necessary for diagnosis and treatment of your enlarged heart. The Plan denied your 
request. The Plan says this request is not medically necessary because your records show you do not have any 
cardiac symptoms, any cardiac history, or any other indications. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms. 
 
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 SPECT scan. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
your clinical management. Our physician reviewer found you have no history of cardiac symptoms. Your pre-
test probability for an abnormal test is low and there is no documentation that the electrocardiogram shows an 
uninterpretable pattern. Our reviewer also found that there is no evidence provided that would support the need 
for radionuclide stress testing. 
 
 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78452).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 12002. 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 93042 
is a column II code to column I code 12002. 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 93042 billed for date of service March 8, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not support 
those services in the home with home health care or in a long-term care facility on a part time basis are not 
appropriate 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult day care services (S5102). 
 
You asked the Plan to pre-approve adult day care services. You say that the enrollee would benefit from the 
adult day care services to help prevent complications of their conditions and assist with compliance and overall 
mental and physical wellbeing of the enrollee. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of adult day care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve adult 
day care services (S5102).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollees ongoing and complex 
medical needs make the enrollee meet the criteria for LTACH admission. The enrollee cannot receive the care 
they need in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to 
LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 17, 2021 to 
October 25, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that DRG 
871 is accurate and supported. The Plan denied your request. The Plan says the diagnosis of sepsis is not 
clinically validated, and the determination to remove principal diagnosis A41.01 (Sepsis due to methicillin 
susceptible staphylococcus aureus) and G93.41 (Metabolic encephalopathy) from the claim is upheld consistent 
with medical record documentation received for review. 
 
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 primary diagnosis code, A41.01, defined as Sepsis 
due to methicillin susceptible staphylococcus aureus and secondary diagnosis code, G93.41, defined as 
Metabolic encephalopathy. 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 submitted DRG is not supported. Our 
physician reviewer found based on the objective information documented in the clinical notes prior to 
admission, the enrollee did not meet the Sepsis 3 criteria and the enrollee was described as alert and oriented 
without abnormal Glasgow Coma Scale (GCS) noted to support the diagnosis of encephalopathy. Our reviewer 
found that therefore, the medical records do not sufficiently support the billing of Sepsis due to methicillin 
susceptible staphylococcus aureus or Metabolic encephalopathy.  
 
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 on October 17, 2021 to October 25, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 22854 (x2) provided on May 25, 2022. 
 
You asked the Plan to pay for code 22854. You say that this claim was billed correctly. The Plan denied your 
request. The Plan says code 22854 (x 2) is not supported in the medical record. This request is for an incorrect 
number of units of service. 
 
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 22854 is Insertion of intervertebral biomechanical 
device(s) (synthetic cage, mesh), with integral anterior instrumentation for device anchoring (screws, flanges) 
when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in 
conjunction with interboday arthrodesis, for each contiguous defect (listed separately in addition tocode for 
primary procedure). 
 
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 code 22854. Our reviewer says that code 22854 (x 2) is not 
supported in the medical record. Our reviewer found the operative report does not include sufficient documentation to confirm per NCCI Policy (Once vertebral body has been removed by a separately identifiable 
procedure, a hole is cored out of the vertebral bodies above and below the removed vertebrae to secure a 
biomechanical device into the resulting intervertebral defect") insertion of intervertebral biomechanical device 
with integral anterior instrumentation for device anchoring, has been performed.  The operative report 
documents "At the C3-C4 segment a high-speed drill was used to remove the anterior hardware and a 
discectomy was performed all the way to the posterior edge of the vertebral body. Once a partial corpectomy of 
C4 was done, wide decompression of the thecal sac was done on either side, removing the ligamentum as well 
as the disc material...A7mm spacer filed with bony allograft was positioned at the intervertebral space at the 
C4-C5 segment....A 30mm plate was placed across from C3-C5 segment and was locked down with 18 and 
20mm screws". In this case, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 22854 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 22854 (x2) provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT testing provided January 24, 2022. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT testing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the Tempus xT testing provided January 24, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
1, 2021 to December 10, 2021. 
 
You asked the Plan to pay for SNF care. You say that these additional SNF days were medically necessary. The 
Plan denied your request. The Plan says continued SNF admission from December 1, 2021, to December 10, 
2021, was not medically necessary. The patient's last covered day was November 25, 2021. As of that date, the 
patient could have received intermittent care on an outpatient basis. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found as of the dates of service in question, the enrollee did not have documented skilled 
nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services are not 
shown to have been required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. 
 
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 pay for skilled nursing facility (SNF) care provided from December 1, 2021 to December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 96372. You say that the service was medically necessary. The 
Plan denied your request. The Plan says payment for code 96372 is bundled into payment for code 10061. 
 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 96372 
is a column II code to column I code 10061. 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 96372 billed for date of service May 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion. 
 
You asked the Plan to pre-approve lumbar fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 lumbar fusion. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested L3-5 lateral lumbar interbody fusion 
with posterior instrumented spinal fusion, 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 lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve a transforaminal epidural steroid injection. You say that a transforaminal 
epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the requested 
transforaminal epidural steroid injection does not meet the Medicare LCD 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 transforaminal epidural steroid 
injection. Our reviewer says that a transforaminal epidural steroid injection is not medically necessary. Our 
physician reviewer found that in this case, the right L5-S1 transforaminal epidural steroid injection on 
July 28, 2022 provided 50% pain relief for a period of two months. The review has determined that the 
requested a repeat transforaminal epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 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 transforaminal epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 20, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, the professional component must be billed with modifier -
26 for payment to be considered. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77067, 77063) provided on June 16, 
2021. 
 
You asked the Plan to pay for the radiology services. You say that two exams were performed. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
Records do not support multiple instances. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 16, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (77067, 77063) provided on 
June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection (62264). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested 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 the injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this injection is considered experimental/investigational. Therefore, the reviewer found that the injection 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous lysis of epidural adhesions using solution injection (62264).