Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (CPT code K0606) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are needed. The Plan 
denied your request. The Plan says there are in-network provider(s) within a reasonable distance from your 
location that can provide this service or item. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT code K0606) to 
be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
April 6, 2021. 
 
You asked the Plan to pay for the hospital discharge day management (99239). You say that the claim should 
be reconsidered with the attached documents and reprocessed for payment. The Plan denied your request. The 
Plan says only one hospital discharge day management service is payable per patient per hospital stay.  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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, only one hospital discharge 
day management service is payable per patient per hospital stay and the Plan paid for CPT code 99238 
provided on Aril 6, 2021. Based on this information, we decided that Medicare rules for coverage of the 
hospital discharge day management (99239) have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge day management (99239) provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization inpatient hospital services provided 
from April 18, 2021, to April 26, 2021. 
 
You asked the Plan to pay for the post stabilization care. You say that the services should be covered. The Plan 
denied your request. The Plan says authorization was not obtained prior to receiving post stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the post stabilization care was not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee was not hemodynamically stable for ambulance transport 
with oxygen/monitoring to a Plan facility after the emergency room evaluation on April 18, 2021. The reviewer 
found that the post-stabilization care services provided from April 18, 2021, to April 26, 2021 were not 
medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, 
or in an order) that the enrollee was not stable for transfer on any dates of service. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization inpatient hospital services provided from April 18, 2021, to 
April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that your primary care provider and cardiologist 
recommended this. The Plan denied your request. The Plan says you need to still be smoking or have stopped 
within the last fifteen years. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found you have a non-
quantified smoking history, and you quit 18 years ago. Based on this, you do not meet the 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 the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says the request does not 
meet the Part B step therapy criteria for the requested viscosupplements device. 
  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 Synvisc. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or 
would have an adverse effect from the Plan's preferred step one alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says step therapy rules for the requested drug 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 Zilretta. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Dexamethasone, Methylprednisolone, and Triamcinolone before they will approve the 
requested drug. The requested drug is a new start. The provided records do not indicate that you have tried and 
failed all of the Plan's preferred step-one alternatives. The record does not indicate that you have a 
contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on 
September 13, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 0242U (1 
Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on September 8, 2021 and received by the lab on September 9, 2021. Of note, the 
patient resides in South Carolina and the billing laboratory is located in Illinois; therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided 
on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 10, 
2020. 
 
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. 
 
We find that CPT codes 87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798 are not supported in the 
medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient 
when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while 
the records reflect of place of service of a skilled nursing facility (POS 31). 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 laboratory services provided to the enrollee on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous Spacer. The Plan denied your request. 
The Plan says this 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 Vertiflex Superion Interspinous 
Spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that current evidence-based medical guidelines 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. 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 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 Vertiflex Superion Interspinous Spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for needle placement (76942) 
provided on July 2, 2021. 
 You asked the Plan to pay for the ultrasound guidance for needle placement. You say that you would like this 
claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim 
has not been billed as required by Medicare coding regulations. 
 
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 76942 
is a column II code to column I code 36556. 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 the ultrasound guidance for needle placement (76942) provided 
on July 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97110), neuromuscular reeducation 
(97112), gait training therapy (97116) and manual therapy techniques (97140) provided on September 1, 2021, 
through September 29, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration because you 
received authorization for these services. The Plan denied your request. The Plan says this is a provider and not 
a facility in which a CMS-1500/HCFA 1500 form should be submitted for services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the required format for submitting professional 
and supplier claims to Medicare on paper is the CMS-1500 claim form. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Specifically, these services have been submitted on an 
inappropriate claim form for physician services. Therefore, we decided that the Plan does not have to pay for 
the therapeutic activities (97110), neuromuscular reeducation (97112), gait training therapy (97116) and 
manual therapy techniques (97140) provided on September 1, 2021, through September 29, 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 as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis including the planned level of implantation at L3-4. FDA 
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately 
addressed in the medical records. There is imaging evidence of levorotatory scoliosis with apex at L3-4 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. MRI demonstrated diffuse osteopenia. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
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 the Intracept procedure. 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 request for Intracept intraosseous 
nerve ablation system at L5-S1 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scan of blood vessels and grafts of heart with 
contrast (CPT code 75574). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has complaints of intermittent chest 
pain and palpitations. The Plan denied your request. The Plan says the following notes should be sent; new 
complaints suggestive of blocked heart arteries that show the need for this test now; or new exam findings that 
show why it is needed. The Plan states please also send the report of the enrollee's last heart catheterization 
including date of exam. The Plan states the information they got did not show that these things have been done 
and it is suggested that the enrollee follows up with their doctor for the next step in their care. 
 
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 service. Our physician reviewer 
found there is no specific clinical rationale for the requested CT scan of blood vessels and grafts of heart with 
contrast (CPT code 75574). The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scan of blood vessels and grafts of heart with contrast (CPT code 75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says total electric beds will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that 
a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is 
a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional computed tomography angiography (CTA) 
services (procedure code 74174) provided to the enrollee on April 13, 2021. 
 
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 there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 74174 is "Computed tomographic angiography, abdomen 
and pelvis, with contrast material(s), including non-contrast images, if performed, and image postprocessing." 
 
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 a review of the records showed a 
single CTA of the aorta done on 4/13/21 and signed by the doctor on 4/14/21. There is no record of a second 
CTA on the same date.  
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 additional computed tomography angiography (CTA) services (procedure code 74174) 
provided to the enrollee on April 13, 2021.