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

 
We decided that the Plan does not have to pre-approve the combined electrochemical therapy (CET) therapy 
(97016, 97112 and 97032). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has suffered with back pain since 
1990. You state the enrollee's pain has recently gotten worse and it is now radiated all the way to the enrollee's 
shins. You state the enrollee's doctor believes the CET therapy will greatly help ease the enrollees pain. The 
Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records 
show you are asking for electrostimulation for the treatment of neuropathy, with the Sanexas treatment. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of "CET" therapy would not be consistent with an indication for which Medicare covers 
the use of NMES. Furthermore, the evidence on the use of CET in neuropathic pain is largely limited to 
manufacturer designed studies with marked methodological limitations. The requested course of 
therapy/treatment has not been shown to have been equivalent to or superior to any other form of management 
of neuropathic pain. Nor is this treatment readily recommended within any practice/professional society 
guidelines for the enrollee's condition. Consequently, this service cannot be said to meet the Medicare 
definition of medical necessity, nor would it be reasonable and necessary 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the combined electrochemical therapy (CET) therapy (97016, 97112 and 97032).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third right side sacroiliac (SI) joint injection (20760). 
 
You asked the Plan to pre-approve the injection. You say that you feel significantly better when you get the SI 
injections. You say that you feel 100% better post injections and can perform daily functions. You also say that 
you have been without an injection for a few months and need help with the pain. The Plan denied your 
request. The Plan says the requested service 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 injection. Our reviewer says that the 
requested sacroiliac (SI) joint injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of tenderness of the SI joint and 
no mention of SI provocative testing being completed with positive findings. The reviewer found that the 
clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative 
testing results have not been demonstrated in the peer-reviewed literature. The reviewer found that you do not 
have a diagnosis or condition that meets the criteria for the requested services. Therefore, the requested 
sacroiliac joint injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a third right side sacroiliac (SI) joint injection (20760).
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 is medically stable to be 
transferred to LTACH level of care. The Plan denied your request. The Plan says the enrollee can remain in the 
current acute care location until such time no further acute level care is needed. A discharge to a lower level of 
care would not be appropriate if the enrollee has ongoing acute care needs. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (99225) provided on December 
30, 2021, to December 31, 2021. 
 
You asked the Plan to pay for observation care. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says the records provided do not support that the enrollee was 
observation status on the date in question. 
 
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 99225 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99225 is not supported in the medical record. Specifically, the records provided do not 
note that the enrollee was observation status at the time of services. In addition, there is no evidence that the 
enrollee has developed a minor complication or that medical decision making of moderate complexity took 
place; the records note that the enrollee was resting comfortably, without complaint, no shortness of breath, no 
abdominal pain, no fever/chills, no nausea/vomiting or diarrhea, and that at the time they were awaiting 
placement in another facility. Based on this information, we decided that Medicare rules for coverage of 
observation care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent 
observation care (99225) provided on December 30, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0463 & M0222) provided on July 21, 
2022. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OCE edit 21 indicates a medical visit on same 
day as a type T or S procedure without modifier 25. This edit indicates a line edit rejection. 
 We looked at the file and Medicare rules. Code G0463 has a status of "V". Code M0222 is assigned status "S". 
These codes were billed the same day as a type T or S procedure and were not billed with modifier 25. 
Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient services (G0463 & M0222) 
provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single and second levels (64493 and 64494) 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 service is medically necessary. 
The Plan denied your request. The Plan says there is an in-network provider that can perform the services you 
need. 
 
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 
the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single and second levels 
(64493 and 64494) to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 October 3, 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 further delay in IRF care will have a detrimental 
effect. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health plan. The health plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
your diagnosis and condition 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic (CT) colonography. 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CT colonography is indicated when a board certified 
or board eligible gastroenterologist, a surgeon trained in endoscopy or a physician with equivalent endoscopic 
training determines from an evaluation of the patient that optical colonoscopy cannot be safely attempted. 
 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that you have a history of a massive 
pulmonary emboli and right heart strain. You are on lifetime anticoagulants. Your last colonoscopy was in 
2010. This service has been requested to look for occult malignancy responsible for hyper coagulopathy. This 
is a reasonable request as you have been seen for clearance by cardiology and the cessation of anticoagulants 
even briefly would be necessary for a direct colonoscopy that has been deemed too dangerous due to the 
massive emboli and right heart strain. This is a unique situation and the performance of a CT colonoscopy is 
indicated and should be approved in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomographic (CT) colonography.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet the guidelines 
for services in an IRF. 
 
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 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 may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
You asked the Plan to pre-approve PTA. 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 the PTA is covered 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 PTA. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the documentation does not meet the coverage 
criteria. The enrollee has had follow-up studies demonstrating stable, normal ankle-brachial index (ABI) and, 
although velocities are elevated in the right superficial femoral stent, there is no change in category of stenosis 
since the recent prior evaluation. There is no plan for intervention documented in the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transluminal angioplasty (PTA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 77061. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery-operated nebulizer (E0570). 
 
You asked the Plan to pre-approve a nebulizer. You say that the nebulizer the enrollee received back in 
November still required it to be plugged in to a wall outlet. The enrollee is about to be evicted from her home 
and needs something that is battery operated. The Plan denied your request. The Plan says the requested item is 
the same as or similar to equipment already in your possession. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was approved for a plug-in nebulizer and received the device in November 
2022. The records show that the nebulizer that the enrollee currently has serves the same purpose as a battery-
operated nebulizer. Therefore, we decided that the Plan does not have to pre-approve a battery-operated 
nebulizer (E0570).