Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV Ketamine for treatment resistant depression. 
 
You asked the Plan to pre-approve IV Ketamine for treatment resistant depression. The Plan denied your 
request. The Plan says IV ketamine for treatment resistant depression is not FDA approved and is not supported 
in the major drug compendia and is not supported in authoritative medical literatures and/or accepted standards 
or medical practice. 
 
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 IV Ketamine for treatment resistant 
depression. Our reviewer says that IV Ketamine for treatment resistant depression is not considered medically 
necessary for the treatment of resistant depressive disorder.  Our physician reviewer found that based on review 
the records and the facilities stance on the use of this procedure utilizing the Medicare LCD L33394 states that 
the use of intranasal Ketamine is considered FDA approved for treatment resistant depression. Based on review 
of the records provided and the literature provided on the use of this procedure is not considered medically 
necessary for the treatment resistant depressive disorder however intranasal ketamine is considered approved 
by the FDA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IV Ketamine for treatment resistant depression have not been met. Therefore, 
we decided that the Plan does not have to pre-approve IV Ketamine for treatment resistant depression.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications and 
had stable vital signs. He was at a supervision/stand by assist to contact guard/minimal assist level for 
functional mobility including gait 300 feet. The enrollee does not require skilled nursing or therapy services on 
a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has knee pain from 
osteoarthritis. The requested drug is being used for its current Food and Drug Administration (FDA)-labelled 
indication. The FDA has not restricted its use to a single time. Zilretta is therefore reasonable and medically 
necessary for the enrollee at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955-26, 95885-26 x 2 and 95909-26-59 
billed for date of service November 9, 2021. 
 
You asked the Plan to pay for procedure codes 95955-26, 95885-26 x 2 and 95909-26-59. You say that the 
medical records support payment of these codes. The Plan denied your request. The Plan says these codes are 
not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. For code 95955-26, the technical report did not 
include documentation of EEG during nonintracranial surgery, so this code cannot be verified. For code 84774-
26 (x2), the technical report did not include documentation of a limited needle electromyography. For code 95909-26-59, the technical report did not include documentation of nerve condition studies, for 5-6 studies, so 
this code cannot be verified.  
 
In this case, the CPT Code Manual definition of code 95955 is Special Electroencephalogram (EEG) Testing 
Procedures, Other EEG Testing Procedures.  The CPT code Manual definition of code 95885 is Needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, 
amplitude and latency/velocity study; limited.  The CPT Code Manual definition of code 95906 is nerve 
conduction studies, 5-6 nerves. 
 
We asked our coder 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 procedure codes 95955-26, 95885-26 x 2 and 95909-26-59. 
Our reviewer says that these codes are not supported by the medical record. Our reviewer found that for code 
95955, the technical report does not support the reporting of this procedure code, as well as any additional EEG 
testing would be inclusive to the interoperative monitoring code.  For code 95885, This procedure per CPT 
code description is "done with nerve conduction studies".  In this case nerve conduction studies cannot be 
verified; therefore, this procedure cannot be verified.  For procedure code 95909, the procedure describes 
pedicle screw stimulation, which would not be reported with nerve conduction studies which measures 
amplitude and latency/velocity.  Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95955-26, 95885-26 x 2 and 95909-26-59 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95955-26, 95885-26 x 2 and 
95909-26-59 billed for date of service November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from December 15, 2021, to 
December 29, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture is a covered service. The Plan denied 
your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is not 
supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided from 
December 15, 2021, to December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve this item. You say that a total electric hospital bed is medically necessary 
for the enrollee. The Plan denied your request. The Plan says a total electric hospital bed is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate for the enrollee in this case, neither the Plan nor 
Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total 
electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam you had on August 12, 2021. 
 
You asked the Plan to pay for the eye exam. You say that you are appealing this claim because it was denied. 
The Plan denied your request. The Plan says this claim needs to first go to your primary employer group 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and instructed them to bill your primary insurer. As the secondary insurer, the Plan cannot be held responsible for the eye exam until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the eye exam you had on August 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on January 8, 2022. 
 
You asked the Plan to pay for the ambulance 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 a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport by the billing party, neither Medicare nor the Plan pays for 
the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment, no transport (A0998) provided on January 8, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need PM&R physician's supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You do not need intensive therapies, (Speech, PT and OT) consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. Your rehab needs can be safely 
provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need PM&R physician's supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach in an IRF. Your rehab needs can be safely provided in a lower 
intensity and alternate setting such as in a skilled nursing facility. 
 
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 pay for an office visit provided on May 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 19, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Principal care management services provided on January 17, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Principal care management services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Principal care management services provided on 
January 17, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Initial hospital care (99223) provided on September 21, 
2021. 
 
You asked the Plan to pay for code 99223. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 99223 
is a column II code to column I code 11043. 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 the Initial hospital care (99223) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit and urology services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit and urology services. You say that you want to 
continue to see this specialist. The Plan denied your request. The Plan says services were requested at an out-
of-network provider, but can be safely provided in-network. 
 
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 
a specialist office visit and urology services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy to be rendered by the out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not payable as the provider is not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that licensed professional counselors are not eligible 
to enroll in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service has not been met. Specifically, the requested provider in this case is a licensed 
professional counselor that is not eligible to enroll in Medicare. Therefore, we decided that the Plan does not 
have to pre-approve outpatient therapy to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on January 7, 2022. 
 
You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for the medical 
services (99053) provided on January 7, 2022.