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

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure: Percutaneous Injection (0627T). 
 
You asked the Plan to pre-approve the procedure. You say that you are filing a review for wrongful denial for 
Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the VIA Disc allograft intervertebral 
disc augmentation in the setting of lumbar degenerative disc disease 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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found This procedure is considered experimental/ investigational.  Therefore, the request is 
considered 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc allograft intervertebral disc augmentation procedure: Percutaneous Injection 
(0627T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three additional home health skilled nursing services 
(G0299 x3) and ten physical therapy services (G0151 x10) provided from January 28, 2022, to April 27, 2022. 
 
You asked the Plan to pay for the home health skilled nursing services and physical therapy services. The Plan 
denied your request. The Plan says the additional home skilled nursing and physical therapy services were not 
medically reasonable or necessary per the documentation. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the home health skilled nursing services and 
physical therapy services. Our reviewer says that the home health skilled nursing services and physical therapy 
services are not reasonable and necessary. Our physician reviewer found the provided records do not document 
any acute or unstable medical conditions or changes in medication or treatment which would necessitate any 
further skilled nursing visits beyond what have already been approved. Our reviewer found that the records 
document the enrollee has been educated on their disease process, medications, home exercise program, and 
safety measures. Our physician reviewer also found that there are no medical notes from the enrollee's treating 
physician are provided documenting an order or need for additional skilled physical therapy 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 the home health skilled nursing services and physical therapy services have not 
been met. Therefore, we decided that the Plan does not have to pay for the three additional home health skilled 
nursing services (G0299 x3) and ten physical therapy services (G0151 x10) provided from January 28, 2022, to 
April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64491 and 
64490). 
 You asked the Plan to pre-approve the facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 the facet joint injections. Our physician 
reviewer found 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (CPT code(s): 64491 and 64490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Remede phrenic nerve stimulator 
(0424T). 
 
You asked the Plan to pre-approve a Remede phrenic nerve stimulator. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says medical-necessity rules for the 
requested service have not been met. 
 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 a Remede phrenic nerve stimulator. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have severe complex sleep apnea, with a combination of obstructive and 
central apneas. Positive airway pressure (PAP) titration found that the apnea was controlled with bi-level 
positive airway pressure (BiPAP) spontaneous/timed (S/T) therapy 20/12. It appears this therapy has not been 
trialed. The phrenic nerve stimulator is for patients with severe chronic hypoventilation, usually requiring a 
ventilator, who have intact phrenic nerve and diaphragm. It is not a preferred treatment for complex sleep 
apnea, especially when BiPAP therapy can be used without the risks associated with implanting the device. No 
reasons are provided that would prevent you from using BiPAP. 
 
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 Remede phrenic nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of a Remede phrenic nerve stimulator (0424T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two collections and applications of autologous blood 
concentrate products (D7921 x2) provided on May 25, 2022. 
 
You asked the Plan to pay for the collections and applications of autologous blood concentrate products. You 
say that you do not have the funds to pay this bill. The Plan denied your request. The Plan says this service is 
not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
collections and applications of autologous blood concentrate products (D7921 x2) provided on May 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you would like ongoing PT services to be 
approved to improve the enrollee's strength, mobility, and function. The Plan denied your request. The Plan 
says these visits are not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee had improved walking distance, but had little impact on 
fall risk. Increased walking distance comes with repetitive exercise. Our reviewer found that the enrollee had 
stabilized in range of motion and fall risk. Our physician reviewer also found that continued input from a 
skilled therapist is not necessary for the enrollee to continue to restore function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76882 is bundled into payment for code 93976. 
 
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 76882 
is a column II code to column I code 93976.  
 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 76882 billed for date of service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that physicians in the same group practice but 
who are in different specialties may bill and be paid without regard to their membership in the same group. 
You say that the records should be reviewed, and the service reprocessed. The Plan denied your request. The 
Plan says a modifier cannot bypass the code edit. 
  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 99232 
is a column II code to column I code 99239 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service April 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that symptoms must be the same or worse after treatment to support 
imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that an MRI 
is medically reasonable and necessary. Previous conservative measures including physical therapy, 
medications, and a cortisone injection were noted to have provided a degree of benefit. However, the pain has 
returned/continues and is associated with significantly abnormal objective findings. The requested shoulder 
MRI would be indicated to evaluate for pathology and to further differentiate a plan for the course of treatment. 
Our physician reviewer found that the enrollee's condition meets criteria for coverage of an MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a CT of the abdomen and pelvis 
provide on December 28, 2021. 
 
You asked the Plan to pay for a CT of the abdomen and pelvis. The Plan denied your request. The Plan says the 
member was enrolled in hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services for a CT of the abdomen and pelvis on 
December 28, 2021.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee has a history of 
cervical spine decompression and fusion and is having increased difficulty with neck pain and activities of 
daily living. The records do not support a need for an intensive therapy program in an IRF. The services are 
therefore not reasonable or 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product (0627T). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested procedure 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 injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found published studies do not demonstrate any long-term health outcome advantage with the use of VIA Disc 
NP as an alternative to standard treatments. Therefore, the reviewer found that the requested 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 percutaneous injection of allogeneic cellular and/or tissue-based product (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on May 20, 
2022. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you should not be responsible 
to pay this because you have never had a podiatry copayment before. The Plan denied your request. The Plan 
says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for the diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as 
hammer toe or heel spurs) and routine foot care for members with certain medical conditions affecting the 
lower limbs.  
 
 
 
 
 You have been asked to pay $40 for podiatry services. Podiatry services falls within the Podiatry Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for podiatry services provided on 
May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on April 27, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denied payment on this claim. 
The lab was medically necessary for future treatment of the enrollee. The Plan denied your request. The Plan 
says the tests are not medically necessary or appropriate for the member with prostate cancer. 
 
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 81432, 81433 is not supported in the medical record. Specifically, the requested genetic 
testing is listed under Group 3, Tier 1, non-covered codes, and is denied as not medically necessary. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee brace (knee orthosis) L1843. 
 
You asked the Plan to pre-approve knee brace. You say that the requested orthosis is medically necessary. The 
Plan denied your request. The Plan says the records do not show recent injury to or surgery on the knee; or that 
the enrollee's knee is unstable. The request 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 knee brace. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the knee brace exceeds the enrollee's medical need. The documentation does not reveal 
objective physical exam evidence of knee instability. There is no evidence of recent injury or surgery to the 
knees. The enrollee is documented to be ambulatory however the requested knee orthosis is not medically 
necessary. Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee brace (knee orthosis) L1843.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the weight management program beginning on February 24, 
2021. 
 You asked the Plan to pay for the weight management program. You say that you would like to be reimbursed 
the full $150. The Plan denied your request. The Plan says you had paid $15 each for six dates of service, 
which equated to $90, and have been reimbursed this amount by the health plan. The Plan also says that you 
cannot be reimbursed for the remaining $60 because no additional documentation was received to indicate you 
had paid for more dates of service. 
 
The Plan must follow Medicare rules. Medicare rules say that weight management programs may be offered as 
a supplemental benefit, and proof of payment must be submitted for reimbursement. 
 
We looked at the file and Medicare rules. The record shows that you submitted receipts for the services 
provided on February 24, 2021, March 16, 2021, April 12, 2021, April 29, 2021, May 26, 2021, and December 
13, 2021, and you have been reimbursed for these dates of service. Duplicate receipts were provided, but there 
is no proof of payment for weight loss programs provided on other dates of service. Based on this information, 
we decided that Medicare rules for coverage of the weight management program have not been met. Therefore, 
we decided that the Plan does not have to pay for the weight management program beginning on February 24, 
2021.