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

 
We decided that the Plan does not have to pre-approve real-time outpatient cardiac telemetry services. 
 
You asked the Plan to pre-approve real-time outpatient cardiac telemetry services. You say that the requested 
heart monitor is medically necessary. You say that the enrollee has been experiencing heart palpitations and 
episodes of shortness of breath. The Plan denied your request. The Plan says the records do not show that the 
enrollee has had any other testing or monitoring hat has been unrevealing. The Plan says that the enrollee does 
not have a known or suspected arrhythmia and the request appears to be for screening causes for shortness of 
breath. 
 
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 real-time outpatient cardiac telemetry 
services. Our reviewer says that real-time outpatient cardiac telemetry services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of palpitations 
and shortness of breath, without syncope, near-syncope, or chest pains. There is insufficient documentation to 
support the medical necessity for a Mobile Cardiac Outpatient Telemetry (MCOT) monitor in this patient's 
clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of real-time outpatient cardiac telemetry services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve real-time outpatient cardiac telemetry services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88361, 88312, 88305, 88104) provided on 
October 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88361, 88312, 88305, and 88104 is not supported in the medical record. Specifically, 
this service has a professional component / technical component indicator of 1. The service with place of 
service 22 (outpatient hospital). The professional interpretation of a diagnostic test must be separately billed 
with modifier 26 by the interpreting physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (88361, 88312, 88305, 88104) provided on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service August 2, 
2021. 
 You asked the Plan to pay for procedure code 20610. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says payment for code 20610 is bundled into payment 
for code 25605. 
 
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 20610 
is a column II code to column I code 25605. 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 20610 billed for date of service August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that the records provided support the need for the 
services in dispute. The Plan denied your request. The Plan says the use of radiofrequency ablation for pain 
management related to sacroilitis has not been shown to provide a clear long-term benefit over standard 
treatment for chronic sacroiliac joint pain. 
 
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 RFA services. Our reviewer says that 
RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in 
efficacy published in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services, the application of 
low-level laser therapy, vertebral axial decompression, and manipulative treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON chiropractic services. You say that the requested provider is the 
only one who able to provide the services that you urgently need to prevent the loss of function in your left 
hand. You say that if you go without treatments, the higher the risk you have of permanent function loss. The 
Plan denied your request. The Plan says the services being requested are not covered by Medicare and are not 
covered when performed by an OON provider. 
 
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 rules also say 
that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that some of the chiropractic services you are requesting include  
evaluation and management services, the application of low-level laser therapy, and vertebral axial 
decompression. These services are not manual manipulation of the spine and are not covered according to 
Medicare rules. You also requested coverage of manipulative treatment. The requested provider in this case is 
not a network provider with the Plan. The Plan has network providers available who can provide the 
manipulative treatment 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 evaluation and 
management services, the application of low-level laser therapy, vertebral axial decompression, and 
manipulative treatment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550, A4556, A4557, and A4649 billed 
for date of service May 21, 2021. 
 You asked the Plan to pay for procedure codes A4550, A4556, A4557, and A4649. You say that you disagree 
with the denial. The Plan denied your request. The Plan says procedure codes A4550, A4556, A4557, and 
A4649 are not 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 A4550 has a status indicator of B on the Physician Fee Schedule. Procedure codes 
A4556, A4557, and A4649 have a status indicator of P. This means that procedure codes A4550, A4556, 
A4557, and A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes A4550, A4556, A4557, and A4649 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes A4550, A4556, A4557, and A4649 billed for date of service 
May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollee's back pain. 
 
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 requested intracept intraosseous 
basivertebral nerve ablation at L5 and S1 vertebral bodies, 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography (CTA) (71275). 
 
You asked the Plan to pre-approve the CTA. You say that the service is necessary. The Plan denied your 
request. The Plan says that 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 CTA. Our reviewer says that the 
requested CTA is considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation indicates that the enrollee has been taking medication for pulmonary embolism 
(PE) documented via CTA of the chest. The reviewer found that due to the recent development of hematuria, it 
is reasonable to look for resolution of clots before discontinuing the use of Eliquis. Therefore, the reviewer 
found that the requested CTA is medically reasonable and 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 CTA have not been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography angiography (CTA) (71275).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of the Medtronic pump (CPT code E0784). 
 
You asked the Plan to pre-approve the pump. You say that you had this device repaired four (4) times and it is 
five (5) years old. The Plan denied your request. The Plan says there are no reports of need for repair and there 
is no documentation from your provider that the Medtronic pump is not meeting your needs. 
 
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 pump have not been met. Review of the file shows that there is 
no documentation from your provider that the Medtronic pump is not meeting your needs and you do not have 
a device that is more than 5 years old. Therefore, we decided that the Plan does not have to pre-approve 
replacement of the Medtronic pump (CPT code E0784).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the drug in 
dispute. The Plan denied your request. The Plan says that the clinical value and effectiveness of continued 
treatment with Keytruda in the setting of disease progression and treatment beyond 24-months have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found use of the requested drug is supported by 
one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
Specifically, oligoprogression supports local therapy to lesion (surgery in this case after Stereotactic Body 
Radiation Therapy) with continuation of pembrolizumab (Keytruda.) This information can be found in a study 
published in the Journal of Thoracic Oncology entitled "Clinical Features and Management of Acquired 
Resistance to PD-1 Axis Inhibitors in 26 Patients with Advanced Non-Small Cell Lung Cancer" and in the 
National Comprehensive Cancer Network (NCCN) guidelines Version 5.2022 Non-Small Cell Lung Cancer. 
The documentation supports that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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 pay for inpatient hospital care provided from January 7, 2022, to 
January 8, 2022, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 191 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the records for this 
inpatient admission. Our physician reviewer found the enrollee with chronic obstructive pulmonary disease 
(COPD) on home oxygen (3L/m baseline at night) was admitted to the hospital and treated for COPD 
exacerbation with steroids, fluids and oxygen support. The enrollee was noted to have leukocytosis, normal 
lactic acid and normal procalcitonin. Following emergency department treatment, blood cultures were negative, 
Glasgow was 15, and platelets, liver function, and kidney function testing was normal with stable vitals. The 
documentation did not meet Sepsis 3 criteria, and the Sequential Organ Failure Assessment (SOFA) score did 
not increase by at least 2 compared to her baseline. There was no evidence of an infection causing organ 
dysfunction. Therefore, the diagnosis of sepsis is not supported by the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 7, 2022, to January 8, 2022, 
as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procalcitonin testing (84145) provided on December 31, 
2021. 
 
You asked the Plan to pay for procalcitonin testing. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says the clinical value and effectiveness of this testing have 
not been demonstrated in peer-reviewed literature and therefore this testing is not medically necessary given 
the clinical scenario and guidance presented. 
 
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 pay for procalcitonin testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that serum procalcitonin measurement indications including aiding in the following: the diagnosis and risk stratification of bacterial sepsis, the diagnosis of renal involvement in children with urinary 
tract infection, and/or distinguishing bacterial from viral infections, including meningitis. There was no specific 
clinical rationale for the test. The review has determined that the items/services at issue in this case were 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 procalcitonin testing have not been met. Therefore, we decided that the Plan 
does not have to pay for procalcitonin testing (84145) provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92526 billed for date of service December 
27, 2019. 
 
You asked the Plan to pay for procedure code 92526. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 92526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92526 billed for date of service December 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiograpy (CTA) of the 
coronary arteries. 
 
You asked the Plan to pre-approve a CTA of the coronary arteries. You say that this test measures for coronary 
blockage due to your cholesterol being high. You also say that high cholesterol runs in your family. The Plan 
denied your request. The Plan says Medicare criteria are not met, and the request for a CTA of the coronary 
arteries is not medically necessary, as you are asymptomatic and you do not have a history of coronary artery 
disease. 
 
The Plan follows Medicare rules. Medicare rules say that a CCTA is never covered for screening, and can be 
covered when the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease. 
 
 
  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 a CTA of the coronary arteries. Our 
reviewer says that a CTA of the coronary arteries is not reasonable and necessary. Our physician reviewer 
found you have no clinical symptoms of heart disease including chest pain, angina, shortness of breath, et 
cetera. You do have elevated cholesterol. Our reviewer found that your risk of coronary event was calculated to 
be greater than 7.5%, but does not exceed 9.9%. Our physician reviewer also found that as such, screening for 
coronary heart disease by CTA is not covered by the Centers for Medicare and Medicaid Services (CMS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CTA of the coronary arteries have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography angiograpy (CTA) of the coronary arteries.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart device (CCM) (CPT code 0408T). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the device has 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found they would not consider the CCM system to be medically 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 
Optimizer Smart device (CCM) (CPT code 0408T).