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

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest 
that this is an appropriate procedure. 
 
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 Intracept. 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, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve intraosseous ablation of the basivertebral nerve (Intracept procedure).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a home evaluation, and how the use of this scooter in the home 
will improve ability to participate in MRADLs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found that the records do 
not support that you require this scooter to accomplish mobility-related self-care tasks within the home. 
Additionally, it is not clear that you are unable to use alternative assistive devices to overcome your deficits. 
 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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on March 1, 
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 code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 the medical records could not be 
verified to show that the patient was in a "critical care area." Furthermore, the medical records do not support 
that the patient met the definition of critically ill meaning "vital organ failure; life threatening health 
condition." Critical care services require high complexity decision making to assess, manipulate, and support 
the vital system functions. The medical records state patient came in for altered mental state with a history of 
other co-morbidities listed, however the medical decision making in this case was not high complexity. There 
was also no mention of the time spent with the patient assessing "critical care needs."  
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 critical care services provided to the enrollee on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography services (procedure codes 93312 and 
93320) provided to the enrollee on April 4, 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 denied codes remain 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 the denied codes is: 
 
CPT 93312: 
 
Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode 
recording); including probe placement, image acquisition, interpretation and report 
 
 
 CPT 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
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 per coding guidelines with ICD 
10 diagnosis crosswalk diagnosis code billed with procedure codes 93312 and 93320 of I35.2 is NOT covered 
with either of these procedure codes and do not medically meet the necessity to be billed. Additionally, the 
medical records do not verify that the services were rendered. 
 
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 echocardiography services (procedure codes 93312 and 93320) provided to the enrollee on 
April 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybelsus tablets. 
 
You asked the Plan to pre-approve Rybelsus tablets. The Plan denied your request. The Plan says Rybelsus is a 
self-administered drug, and does not fall under Part B coverage. 
 
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 Rybelsus tablets.  
 
Benefits for Rybelsus tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasonic guidance. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 ultrasonic guidance. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that ultrasonic guidance is a technology for which medical need has not been established by 
published data or supported by consensus guidelines. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for radiation therapy (G6001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are 
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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate 
the safety and effectiveness of the procedure. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 the enrollee was admitted to the acute care hospital with mesenteric abscess for 
perforated diverticulum, adenocarcinoma of colon requiring drains, antibiotics, debridement, lysis of adhesions, 
laparotomy, bile leak repair, wound VAC, anemia requiring blood transfusion, pain medication, and parenteral 
nutrition. Recent notes describe the enrollee as still with drains in place, having difficulty tolerating soft food 
and on total parenteral nutrition via PICC line and severe anemia.  
 
 The enrollee appears to still be somewhat unstable but improving and should only require short term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 
 
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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee replacement. 
 
You asked the Plan to pre-approve a right total knee replacement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested surgery services are not medically 
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 a right total knee replacement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 74-year-old female being treated for osteoarthritis of 
the right knee. She presented with bilateral knee pain. She received injections in June that were only helpful for 
about 2 weeks. Her right knee is hurting worse than her left. Her pain is 3/10 at rest and 7/10 with weight 
bearing activities. The exam of the right knee reveals range of motion of 0-130. Strength is 5/5. 
 
In this case, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There is no documentation of a formal therapy 
program. She is noted to have had injections; however, the type of injection was not clearly documented. Detailed documentation is not evident regarding attempts at weight loss. Additionally, the most recent exam 
did not demonstrate significant objective deficits in the right knee. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested right total knee replacement, 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 a right total knee replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total knee replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TDAP and Shingles vaccines (90471, 90472, 90714, 90750) 
provided on June 16, 2022. 
 
You asked the Plan to pay for the vaccines. You say that the vaccinations were medically necessary and should 
be covered. The Plan denied your request. The Plan says these immunizations are not eligible for coverage 
under the Part B medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccines. 
Therefore, we decided that the Plan does not have to pay for TDAP and Shingles vaccines (90471, 90472, 
90714, 90750) provided on June 16, 2022.  
 
Benefits for the vaccines 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on April 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until August 23, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the emergency room services rendered on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on May 4, 
2022. 
 
You asked the Plan to pay for the moderate sedation services (99152). You say that medical records are 
attached. The Plan denied your request. The Plan says the documentation does not indicate the presence of a 
trained observer. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical records do not 
support the presence of a trained observer as required by the code billed. Based on this information, we decided 
that Medicare rules for coverage of the moderate sedation services (99152) have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99152) provided on May 4, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the CGM monitor and supplies. You say that you need the Freestyle Libre 
to take your blood sugar. The Plan denied your request. The Plan says the records do not show that the enrollee 
meets the medically necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM monitor and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve a repeat facet joint RFA procedure. You say that you need these injections 
because you are in pain. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent 
improvement in the ability to perform previously painful movements and activities of daily living as compared 
to baseline measurement using the same scale. 
 
We looked at the file and Medicare rules. The submitted records do not show that the previous RFA procedure 
provided at least 50% relief or improvement. Based on this information, we decided that Medicare rules for 
coverage of a repeat facet joint RFA procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat facet joint radiofrequency ablation (RFA) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for managing 
the enrollee's medical condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Specifically, the medical records indicate the enrollee receives 2 insulin 
injections a day. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous 
glucose monitor (CGM).