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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 25, 2022.
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 enrollee is stable and suitable for 
transfer to LTACH. The Plan denied your request. The Plan says the request is not medically necessary, the 
enrollee may continue to receive these safely in a Skilled Nursing Facility (SNF). 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive with image guidance services. 
 
You asked the Plan to pre-approve arthrodesis services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that arthrodesis is only covered for certain indications. 
 
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 arthrodesis services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee was being treated for sacroiliitis not elsewhere classified. The enrollee 
presented with continued SI joint pain. The enrollee presents with a walker for ambulation. The enrollee notes 
that the enrollee has had at least two right SI joint injections. They both gave the enrollee at least 75% relief of 
pain. The enrollee notes her pain is very severe. Exam reveals right posterolateral pelvis tender to palpation 
over the sacral sulcus (Fortins point) just inferior to the posterior superior iliac spine. Pain is reproduced in this 
area and concordant to the normal pain location with pelvic distraction, lateral iliac compression, sacral 
compression/thrust test, thigh thrust test, FABER, and Gaenslens test. There is L5 distribution paresthesias 
specifically with provocation of the SI joint. However, detailed documentation is not evident regarding a trial 
and failure of bracing. Additionally, the diagnostic imaging of the lumbar spine does not rule-out neural 
compression or other degenerative condition that can be causing low back or buttock pain. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the enrollee does not meet ALL of the criteria in the LCD 
above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive with image 
guidance services.
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 enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an LTACH care. When the enrollee is ready to leave the hospital, 
they can safely receive care in another setting such as a Skilled Nursing Facility (SNF) or at home with home 
health services or outpatient 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is required in order for the enrollee to 
return to prior level of function. The Plan denied your request. The Plan says your request is not medically 
necessary at this time. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for rib fractures and pulmonary contusion after a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the medical records support a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wedge pillow (E1399). 
 
You asked the Plan to pre-approve a wedge pillow. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wedge pillow (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
(78452). 
 
You asked the Plan to pre-approve SPECT imaging. You say that the enrollee requires this stress test to 
evaluate their cardiac status. You say that the enrollee has not been diagnosed with chronic kidney disease. You 
also say that it is imperative this testing be completed. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
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 SPECT imaging. Our reviewer says that 
the requested SPECT imaging is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee has cardiac symptoms. The reviewer found there is no 
documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or that the enrollee is unable 
to exercise. There is no evidence provided that would support the need for radionuclide stress testing at this 
time. Therefore, the reviewer found that the requested SPECT imaging 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 SPECT imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve single photon emission computed tomography (SPECT) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (VIA Disc NP) (0627T). 
 
You asked the Plan to pre-approve VIA Disc NP procedure. You say that the requested service is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested service is 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 VIA Disc NP procedure. Our reviewer 
says that the requested VIA Disc NP procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is considered experimental. Therefore, the 
reviewer found that the requested procedure 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 VIA Disc NP procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (VIA Disc 
NP) (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection and positioning wheelchair seat 
cushion, adjustable, width less than 22 inches, any depth (E2624). 
 You asked the Plan to pre-approve a wheelchair seat cushion. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee's current cushion was replaced last year in 
September, and his medical condition has not changed. The request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show the current seat cushion was replaced in September 
2021, and the enrollee's condition has not changed. The seat cushion has not exceeded its reasonable useful 
lifetime of thirty-six months. Based on this information, we decided that Medicare rules for coverage of a 
wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth 
(E2624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compound ketotifen bulk powder, starch bulk powder, 
gelatin capsule. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says compounded Ketotifen bulk powder, starch bulk powder, gelatin 
capsule 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 compound ketotifen bulk 
powder, starch bulk powder, gelatin capsule.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 49020-XS and 49905 billed for date of 
service June 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the treatment was rendered in an emergency 
situation. The Plan denied your request. The Plan says the billed codes 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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). We find that CPT code 49905 is not supported in the medical records. 
The billed code is not described in the services provided to the enrollee.  
 
The CPT code Manual definition of code 49020 is drainage of peritoneal abscess or localized peritonitis, 
exclusive of appendiceal abscess, open. We find that CPT code 49020 is bundled into payment for code 43840. 
The records do not show that code 49020, billed with the XS modifier, was performed on a separate organ or 
structure. 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 codes 49020-XS and 
49905 billed for date of service June 17, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from January 6, 2022 to 
July 6, 2022. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that you have been a patient of this 
provider for years and her care has been beneficial for you. The Plan denied your request. The Plan says this 
type of provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to reimburse you for psychotherapy provided from 
January 6, 2022 to July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig, any type, each (A9282) and sales tax (S9999) 
purchased June 9, 2022. 
 
You asked the Plan to pay for the wig. You say that in preparation for total hair loss, you purchased a cranial 
prosthesis. You provided a prescription form your Oncologist for the cranial prosthesis and submitted the 
receipt for purchase. The Plan denied your request. The Plan says if you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wig, any type, each (A9282) and 
sales tax (S9999) purchased June 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing and debridement services rendered on June 13, 
2022. 
 
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 enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the nursing and debridement services rendered on June 13, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs 
Retacrit or Procrit. The Plan states there is no indication the preferred drug(s) would likely be: less effective, 
and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Retacrit or Procrit before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) would likely be less effective and/or likely 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epogen (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on  
September 8, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that services were medically 
necessary. The Plan denied your request. The Plan says that medical nutrition therapy is covered by Medicare 
only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Parenteral nutrition supply kit, Parenteral nutrition solution 
and Parenteral nutrition administration kit provided on October 2, 2021. 
 
You asked the Plan to pay for Parenteral nutrition supply kit, Parenteral nutrition solution and Parenteral 
nutrition administration kit. The Plan denied your request. The Plan says the documentation submitted did not 
include an itemized shipping billing invoice to indicate the specific supplies or proof of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Parenteral nutrition supply kit, 
Parenteral nutrition solution and Parenteral nutrition administration kit have been met. The documentation 
submitted did not include an itemized shipping billing invoice to indicate the specific supplies or proof of 
delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for Parenteral nutrition supply kit, Parenteral 
nutrition solution and Parenteral nutrition administration kit provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64454) provided on August 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says procedure code 64454 
has not met the associated diagnosis code relationship criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for CPT code 64454 is limited to only 
certain diagnosis codes. 
 
We looked at the file and Medicare rules. Per A57452, diagnosis code M17.11 is not listed as a covered 
diagnosis code for CPT code 64454. 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 the services 
(64454) provided on August 12, 2022.