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

 
We decided that the Plan does not have to pay for the surgical procedures billed with codes 37224, 75716, and 
75774. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 37224 is not supported and codes 75716 and 75774 are inclusive to 
another billed code. 
 
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 37224 is revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. 
 
We find that CPT code 37224 is not supported in the medical record. Specifically, there is no documentation of 
an open or percutaneous endovascular revascularization of a unilateral femoral or popliteal arteries with 
transluminal angioplasty. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met.  
 
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 codes 75716 and 75774 are column II codes to 
column I code 37224. Given that code 37224 is not supported, codes 75716 and 75774 are also not covered as 
they are inclusive to the payment of code 37224. The codes were not billed with an appropriate modifier to 
bypass the edit. 
 
Therefore, we decided that the Plan does not have to pay for the surgical procedures billed with codes 37224, 
75716, and 75774.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95886, 95913, and 95937 provided on April 15, 2022. 
 
You asked the Plan to pay for codes 95886, 95913, and 95937. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 95886, 95913, and 95937 are not supported in the medical record. Specifically, the 
technical report did not include documentation of a complete needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; 
for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. 
 
The technical report did not include documentation of a nerve conduction studies for 13 or more studies; 
therefore, code 95913 cannot be verified. 
 
The technical report did not include documentation of a neuromuscular junction testing (repetitive stimulation, 
paired stimuli) for each nerve, by any 1 method; therefore, code 95937 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 95886, 95913, and 95937 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 95886, 95913, and 
95937 provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on October 10, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered 
by an out-of-network provider. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan provides supplemental coverage for 
routine chiropractic services when rendered by a participating provider.  
 
The records show that the service at issue is not manual manipulation of the spine.  Additionally, the Plan contract states that supplemental coverage is provided for routine chiropractic services 
when rendered by a participating provider. The routine chiropractic service at issue in this case was rendered 
by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (98943) provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kerecis Omega3 skin substitute (Q4158). 
 
You asked the Plan to pre-approve the skin substitute. You say that the enrollee has an open wound on the foot 
and is at risk of infection. The Plan denied your request. The Plan says the enrollee's records do not show that 
the enrollee has enough blood flow for wound healing. The Plan states the enrollee's physical examination 
demonstrates multiple findings consistent with decreased blood flow and the enrollee's records do not show that 
the enrollee has had a formal evaluation of the enrollee's vascular supply, or that steps have been undertaken to 
improve the enrollee's blood supply. 
 
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 skin substitute. Our physician 
reviewer found the records show an abnormal vascular exam of the lower extremities and findings consistent 
with decreased blood flow and the records do not show that the enrollee has had a formal evaluation of the 
enrollee's vascular supply. 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 skin substitute have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Kerecis Omega3 skin substitute (Q4158).
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 enrollee will clearly benefit from IRF care to 
optimize level of functioning prior to returning home The Plan denied your request. The Plan says based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted navigation for a reverse total 
shoulder arthroplasty and biceps tenodesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says computer-assisted navigation 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there are no large volume, long-
term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of functional 
improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total 
shoulder arthroplasty. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested computer-assisted navigation for 
the approved reverse total shoulder arthroplasty and biceps tenodesis, in this case, 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted navigation for a reverse total shoulder arthroplasty and biceps tenodesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92653 and 95941 billed for date of service 
September 13, 2022.  

You asked the Plan to pay for procedure codes 92653 and 95941. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says that code 92653 has not been billed correctly and 
that code 95941 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 92653 has been billed with modifier 26. Procedure code 92653 has a 
professional/technical component indicator of 0. Modifiers 26 and TC cannot be used with codes with an 
indicator of 0. Additionally, we find that procedure code 95941 has a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure code 95941 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 92653 and 95941 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 92653 and 95941 billed for date 
of service September 13, 2022.
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, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. 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 November 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system, a pneumatic propulsion tire (E2211), a 
thumb guard natural fit handrim (K0108), a handrim spacer (K0108), a power add-on to convert manual 
wheelchair to motorized wheelchair, joystick control (E0983), a velcro strap set (K0108), a swivel arm for 
control unit (K0108) and a bracket for control unit (E1028). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested 
wheelchair accessories. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home. 
 
We looked at the file and Medicare rules. The transit system is for use outside of the home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. The file shows that a 
pneumatic propulsion tire, a thumb guard, handrim spacer, velcro strap set, swivel arm for control unit and 
bracket for a control unit is not billed separately. These items do not have a separate payment upon initial issue 
of the manual wheelchair. The power add-on to convert the manual wheelchair are not covered by Medicare as 
they are determined to be neither reasonable nor necessary. Based on this information, we decided that 
Medicare rules for coverage of manual wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transit system, a pneumatic propulsion tire (E2211), a thumb guard 
natural fit handrim (K0108), a handrim spacer (K0108), a power add-on to convert manual wheelchair to 
motorized wheelchair, joystick control (E0983), a velcro strap set (K0108), a swivel arm for control unit 
(K0108) and a bracket for control unit (E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vehicle lift. 
 
You asked the Plan to pre-approve a vehicle lift. You say that the requested item is a medical necessity for you. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that elevators are not covered because they 
are not primarily medical in nature.  
 
While a vehicle lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a vehicle lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on February 24, 2021. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that the 
printed date is the date of submission and is well within the Plan's deadline. The Plan denied your request. The 
Plan says according to Medicare guidelines an original claim submission must be filed to the appropriate 
Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services 
were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric diagnostic evaluation with medical services was not filed until 
October 19, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic 
evaluation with medical services provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested fact joint injections do not meet the 
Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the enrollee is has a 
history of chronic low back pain. The enrollee has low back pain that radiates into the left buttock. The enrollee 
has been treated with medical therapy, chiropractic therapy, an epidural steroid injection and previous left L4-
L5, L5-S1 facet joint injections. In this case, the enrollee has had previous facet injections at L4-L5, and L5-S1. 
Intra-articular (IA) facet blocks are considered reasonable and necessary as a diagnostic test only if medial 
branch blocks (MBBs) cannot be performed due to specific documented anatomic restrictions or there is an 
indication to proceed with therapeutic intra-articular injections. There are no documented restrictions provided 
in the medical record. The review has determined that the requested fact joint injections do not meet the 
Medicare LCD coverage 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical items or services. 
 
You asked the Plan to pre-approve medical items or services. You say that the request is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of medical items or services have not been met. Specifically, we have confirmed that you do not have 
one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not 
have to pre-approve medical items or services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair identified with 
code K0004, and accessories identified with codes E0973, E0971, E0951, E0978, E2611, and E2601. 
 
You asked the Plan to pre-approve a high strength lightweight wheelchair and accessories. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for a replacement wheelchair. 
 
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 has a wheelchair. The enrollees current wheelchair is only one year old and is 
working well. The enrollees current wheelchair serves the same purpose as the requested wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a high strength lightweight wheelchair 
identified with code K0004, and accessories identified with codes E0973, E0971, E0951, E0978, E2611, and 
E2601.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the allograft is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Infuse BMP Allograft in the 
setting of posterior lumbar spine fusion surgery with the Johnson & Johnson DePuy Synthes Concorde cage 
have not been demonstrated in the peer-reviewed literature. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found BMP in the posterior spine is off-label and not Food and Drug Administration (FDA) approved. 
Iliac crest is the best available bone graft option. BMP is not medically needed. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse BMP allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on June 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery payment for the procedure (17262) provided on the same date. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the services (99213) provided on June 14, 2022.