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 November 
11, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple procedures on this 
date of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 
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 November 11, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which 
have not been adequately addressed in the medical records. There is no documentation of the enrollees height, 
weight or body mass index.  There is imaging evidence of subtle levoscoliosis of lower lumbar spine (versus positioning), with no 
documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the 
lack of significant osteoporosis in this patient. 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 request for Vertiflex Superion interspinous device at L3-4 and L4-5 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of an ankle fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided September 13, 
2021. 
 You asked the Plan to pay for the drug testing. You say that it is your position that the services performed by 
you have met the medical necessity criteria as indicated. The Plan denied your request. The Plan says the Plan 
does not cover definitive testing on the same day as a presumptive drug test. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the definitive drug testing (G0483) provided September 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. The Plan denied your request. The Plan says the requested drug is 
intended for self-administration and covered under Medicare Part D. 
  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 Repatha.  
 
Benefits for Repatha 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 pay for the percutaneous transluminal revascularization (92944) 
provided on July 21, 2021. 
 
You asked the Plan to pay for the percutaneous transluminal revascularization (92944). You say that the 
medical records and Waiver of Liability are attached. You say that the claim should be reviewed and 
reprocessed with the inpatient authorization. The Plan denied your request. The Plan says bundled services are 
not eligible for separate payment. 
 
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 92944 is percutaneous transluminal revascularization of 
chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any 
combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary 
artery branch, or bypass graft (List separately in addition to code for primary procedure). 
 
We find that CPT code 92944 is not supported in the medical record. Specifically, CPT code 92944 has a status 
indicator of B. This means that CPT code 92944 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the percutaneous transluminal 
revascularization (92944) have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous transluminal revascularization (92944) provided on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have not been offered any physical therapy at 
the current location and that is one of the reasons you want to move to the other location. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an inpatient 
rehabilitation facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous device placement (22612). 
 
You asked the Plan to pre-approve the interspinous device placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is investigational and non-covered. 
 
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 interspinous device placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the procedure at issue is still considered experimental. More research is needed 
to show safety and efficacy. 
 
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 interspinous device placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous device placement (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from September 7, 2021, 
through September 21, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says outpatient 
physician office visits are covered by Medicare; however, the provider is not under contract with the health 
Plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided from September 7, 2021, through September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64633, 64634). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your request is not medically necessary because your records show your most recent cervical radiofrequency ablations were performed over two years ago and no subsequent 
medial branch blocks have been performed at the requested levels. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation can be covered if 
Medicare criteria have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. You have a history 
of chronic neck pain and low back pain. You have been treated with medical therapy and facet joint injections. 
You have undergone prior radiofrequency ablations. Your most recent cervical radiofrequency ablation was in 
2019. The records show that the most recent cervical radiofrequency ablations were performed over two years 
ago and no subsequent medial branch blocks have been performed at the requested levels. Our physician 
reviewer found that your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (64633, 64634).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided April 13, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you would like this bill covered. The Plan 
denied your request. The Plan says this service is not covered because you were not transported. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 13, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided April 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439) brief communication, 
virtual check-in (G2012) provided June 23, 2021 to June 29, 2021. 
 
You asked the Plan to pay for the telehealth office visit. You say that changed modifier 95 to CR per the Plan's 
telehealth guidelines. Please reprocess. The Plan denied your request. The Plan says the provider did not bill 
the claim as directed by CMS. 
 
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 find that CPT code G0439 and G2012 is not supported in the medical record. Specifically, the claim was billed with an office place of service code while the records suggest this was rendered in a facility. 
Based on this information, we decided that Medicare rules for coverage of the telehealth office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) brief 
communication, virtual check-in (G2012) provided June 23, 2021 to June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid artery stent placement (36222, 36221, 37215, 
36223). 
 
You asked the Plan to pre-approve the carotid artery stent placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical trial and 
therefore this procedure is not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers PTA of the carotid artery 
concurrent with carotid stent placement when furnished in accordance with the FDA-approved- protocols 
governing Category B IDE clinical trials. 
 
We looked at the file and Medicare rules. The record does not show that this procedure is being performed as 
part of a clinical trial. Based on this information, we decided that Medicare rules for coverage of the carotid 
artery stent placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
carotid artery stent placement (36222, 36221, 37215, 36223).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Lucentis. Our reviewer says that the 
requested use of Lucentis is not supported. Our physician reviewer found based on the medical records 
provided and the Medicare-approved major drug compendia, there is no documentation that the requested use 
of Lucentis is Food and Drug Administration-approved for the enrollees diagnosis. The use of Lucentis for 
cystoid macular edema is not safe, effective, and otherwise reasonable and necessary for this 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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight manual wheelchair (K0005) and related 
accessories. 
 
You asked the Plan to pre-approve an ultralight manual wheelchair. You say that this manual wheelchair is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a high strength lightweight wheelchair is covered 
when a beneficiary is able to self-propel the wheelchair while engaging in frequent activities in the home that 
cannot be performed in a standard wheelchair or the beneficiary requires a seat width, depth, or height that 
cannot be accommodated in a standard, light weight or hemi-wheelchair, and spends at least two hours per day 
in the wheelchair. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected 
duration of need is less than 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 an ultralight manual wheelchair. Our 
reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer 
found the member is an 81-year-old female with a medical history including atrial fibrillation, urinary retention 
with an indwelling urinary catheter, heart disease and dementia who resides in a nursing facility memory care 
unit.  She has a clinically significant kyphosis and is not safe to ambulate.  She requires moderate assistance for 
transfers. In this case, the member has advanced dementia with cognitive impairment. There is no indication 
from the documentation that she would be able to self-propel the wheelchair while engaging in ADLs. 
Furthermore, there is no indication that a manual wheelchair cannot be used by staff to propel the member. 
 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 ultralight manual wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an ultralight manual wheelchair (K0005) and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 
7, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that you are appealing for 
consideration of payment for CPT codes 99152 and 99153. The Plan denied your request. The Plan says CPT 
code 99152 has been overturned. The Plan also says that CPT code 99153 may not be paid if furnished to 
hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 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; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor.  Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on October 7, 2021.