Persius/hicric huggingface dataset:
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 received 
clearance from the Food and Drug Administration (FDA), which means that it is safe and effective. The 
appellant says that the enrollee has failed non-operative treatment and the Intracept procedure is the only 
solution, as no other procedure ablates the basivertebral nerve which is the source of the chronic low back pain. 
The Plan denied your request. The Plan says the Intracept procedure is unproven and not medically necessary 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The 
persistent back pain and intact neurologic exam are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 pay for the chest x-ray (CPT code 71045-26) provided on April 26, 
2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was billed with an inappropriate place of service 22 (outpatient). 
 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 chest x-ray have not been met. The claim was billed with an 
inappropriate place of service 22 (outpatient). The enrollee was registered as inpatient of a hospital from April 
25, 2022, through April 28, 2022; therefore, it would be inappropriate to report CPT 71045-26 in outpatient 
place of service 22. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 
71045-26) provided on April 26, 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 due to duration and severity of wounds 
and previously failed outpatient treatment LTACH is the desired placement for enrollee with what we believe 
will be the best possible outcome. The Plan denied your request. The Plan says the request fails to meet the 
definition of reasonable and necessary. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 billed for date of service January 5, 
2022. 
 
You asked the Plan to pay for procedure code A4649. You say that the service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4649 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4649 has a status indicator of B on the Physician Fee Schedule. This means that procedure code A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4649 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4649 billed for date of service January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00530 provided on March 17, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was not billed as required by 
Medicare billing 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.  
 
We looked at the file and Medicare rules. In this case, this claim was billed in addition to another anesthesia 
service that was previously paid for by the Plan without a required modifier. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services coded 00530 provided on March 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve the routine transportation trips. You say that you have one leg and are in a 
wheelchair. You say that it is difficult to get around. You say that you really need to get to your physical 
therapist's office. The Plan denied your request. The Plan says neither they nor Medicare covers routine 
transportation. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the routine transportation trips have not been met. Therefore, we 
decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has ongoing and complex 
medical needs that cannot be met at a lower level of care. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and the enrollee's needs can be met at a lower level of care such as an 
inpatient rehabilitation facility or a skilled nursing facility. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa knee injections. 
 
You asked the Plan to pre-approve Euflexxa knee injections. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa knee injections. Our reviewer 
says that the documentation does not support that the requested Euflexxa knee injections are medically 
reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis/medical history of bilateral 
knee osteoarthritis with knee pain. The enrollee received three injections of Euflexxa for both knees in March 
and April 2022 which were reported to be "ineffective". The effectiveness of more than one treatment course of 
Euflexxa has not been established. Therefore, the enrollee does not meet criteria for the requested 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 Euflexxa knee injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa knee injections.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for a femur fracture. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on March 5, 2022, to May 26, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 11, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the inpatient care have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient care provided on March 5, 2022, to May 26, 2022.
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 IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
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 that clinical documentation shows that you have functional impairments; however, 
there is no documented IRF-compliant diagnosis or complex impairments warranting interdisciplinary team management or intense therapy. Additionally, there is no documentation from evaluating therapists that show 
you would be able to tolerate 3 hours of therapy per day. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service July 6, 
2021. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, if the specimen was stored for more than 30 
calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service 
must be the date the specimen was obtained from storage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the case record indicates the specimen was stored 
for more than 30 calendar days before testing. The case record does not support that July 6, 2021, was the date 
the specimen was obtained from storage. Therefore, we decided that the Plan does not have to pay for genetic 
testing (0037U) billed for date of service July 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
27, 2022 to March 17, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received no skilled 
therapy during this timeframe.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have documented skilled nursing or skilled therapy needs. 
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs could, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 27, 2022 to March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequencing genetic testing services 
provided on April 1, 2022. 
 
You asked the Plan to pay for the next generation sequencing genetic testing services. You say that you would 
like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the 
criteria for the ordered testing have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is only 
covered when the patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support that the enrollee had 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, 
we decided that Medicare rules for coverage of the next generation sequencing genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the next generation sequencing genetic 
testing services provided on April 1, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR). 
 
You asked the Plan to pre-approve TAVR. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TAVR is covered for the treatment of symptomatic 
aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication 
and when specific criteria are 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 TAVR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation supports the presence of 
severe aortic regurgitation, but not aortic stenosis. Guidelines would not support the use of TAVR for this 
indication for a number of reasons, including the lack of aortic valve calcification in many such patients which 
can make anchoring of the new valve challenging. While there have been several promising clinical studies, 
there remain calls for continued clinical trials to assess the efficacy of TAVR for aortic regurgitation. Until 
such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At 
the current time, TAVR would not be considered medically necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter aortic valve replacement (TAVR).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on June 4, 2022, to June 7, 
2022 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that these services were correctly denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission, the admitting physician reasonably 
expected the enrollee's hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on June 4, 2022, to June 7, 2022  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99350 billed for date of service December 7, 
2021. 
 
You asked the Plan to pay for procedure code 99350. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99350 is bundled into payment for code 97167.  
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 99350 
is a column II code to column I code 97167. 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 99350 billed for date of service December 7, 
2021.