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

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you have zero pain 
relief from a prior ESI. There is NO indication to repeat a failed injection. The request 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the wrist (73110) provided on September 
29, 2020. 
 
You asked the Plan to pay for the X-ray exam of the wrist. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 3, 2020. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the X-ray exam of the wrist have not been 
met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the wrist (73110) provided 
on September 29, 2020.
Appeal type: Surgery
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 requested procedure fills a 
treatment gap for those patients that do not receive adequate relief from traditional conservative methods and 
don't have instability to indicate fusion is the appropriate treatment. You say that the Intracept procedure 
received initial FDA clearance which means that it is safe and effective. The Plan denied your request. The 
Plan says there is little evidence in medical literature to suggest that this is an appropriate procedure for back 
pain. The Plan says that it is not an accepted standard of medical practice for the diagnosis or treatment of back 
pain. The Plan says that the requested procedure is considered experimental and investigational. 
 
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 an Intracept procedure is 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 34705, 34713 and 37242 billed on 
November 9, 2021. 
 
You asked the Plan to pay for procedure codes 34705, 34713 and 37242. You say that the operative reports 
support 34705, 34713 and 37242. You say that the claim should be reviewed and reprocessed. The Plan denied 
your request. The Plan says procedure codes 34705, 34713 and 37242 are not supported by the medical records 
submitted. 
 
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 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 34705, 34713 and 37242. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the operative report does not describe the procedure per the description of CPT code 34705. The 
documentation does not support the code description for CPT code 34713 and there is a more appropriate code 
to report for the service documented. In addition, CPT code 37242 also cannot be verified in the operative 
report. 
 
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 34705, 34713 and 37242 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 34705, 34713 and 37242 billed on November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve injections to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 
injections to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence panel of 51 or greater genes 
(81455) provided May 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services were rendered in a good faith 
effort to diagnose or treat the enrollee's medical condition. The Plan denied your request. The Plan says the 
records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the targeted genomic sequence panel 
of 51 or greater genes (81455) provided May 12, 2021. have been met. Despite outreach attempts made by the 
Plan, the provider has not provided the laboratory report to document the molecular diagnostic tests 
performed.. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence panel 
of 51 or greater genes (81455) provided May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves 
(E0673) provided to the enrollee on December 9, 2021. 
 
You asked the Plan to pay for the pneumatic compression device and sleeves. You say that this was issued to 
the patient for use during surgery. The Plan denied your request. The Plan says that the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as E0675 
to treat peripheral arterial disease (PAD) is not eligible for reimbursement 
 
We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the 
Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) 
and sleeves (E0673) provided to the enrollee on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS) 
device. 
 
You asked the Plan to pre-approve the PENS device. You say that the enrollee has attempted to alleviate pain 
with conventional treatment including physical therapy, and nerve blocks, but her pain and functional 
limitations persist. You say that the enrollee has also failed or has not sustained long-term benefit from 
pharmacological therapies. The Plan denied your request. The Plan says the STIMQ peripheral nerve stimulator 
system does not fit the Medicare definition of an implanted peripheral nerve stimulator. 
 
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 PENS device. Our reviewer says 
that the PENS device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the PENS device is experimental for cases of chronic pain. 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 the PENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous electrical nerve stimulation (PENS) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy, with ureteral catheterization, with or 
without irrigation, instillation, or ureteropyelography, exclusive of radiologic service (52005), 
cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; small bladder 
tumor(s) (0.5 up to 2.0 cm) (52234) cystourethroscopy, with fulguration (including cryosurgery or laser 
surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) (52235), and cystourethroscopy, with 
fulguration (including cryosurgery or laser surgery) and/or resection of; large bladder tumor(s) (52240) to be 
performed by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the cystourethroscopy procedures to be performed OON. You say that the 
enrollee has seen this provider in the past with an OON authorization. The Plan denied your request. The Plan 
says criteria for OON coverage are not met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 cystourethroscopy procedures to be 
performed OON. Our reviewer says that it is not medically reasonable and necessary for the cystourethroscopy 
procedures to be performed OON. Our physician reviewer found that the requested care is routine care. These 
procedures can be handled by an in-network urologist. 
 
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 cystourethroscopy procedures to be performed OON have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cystourethroscopy, with ureteral 
catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service 
(52005), cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; small 
bladder tumor(s) (0.5 up to 2.0 cm) (52234) cystourethroscopy, with fulguration (including cryosurgery or laser 
surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) (52235), and cystourethroscopy, with 
fulguration (including cryosurgery or laser surgery) and/or resection of; large bladder tumor(s) (52240) to be 
performed by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric bed (E0260) and an innerspring mattress 
(E0271). 
 
You asked the Plan to pre-approve a semi-electric bed and an innerspring mattress. You say that attached 
medical records confirm the medical necessity of the requested items. The Plan denied your request. The Plan 
says the documentation received does not support the necessity of the semi-electric bed and accessories. 
 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric bed and an innerspring 
mattress. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
according to Medicare a semi-electric hospital bed is medically necessary when a patients condition must 
require frequent changes in body position and/or there may be an immediate need for a change in body position 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. The documentation does not support that 
the enrollee has a condition that requires frequent positioning of the bed and mattress to alleviate pain, promote 
good body alignment, prevent contractures or avoid respiratory infections in a way that an ordinary bed is not 
able to. 
 
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 semi-electric bed and a innerspring mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a semi-electric bed (E0260) and an innerspring mattress 
(E0271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrodesis (22600) provided on October 14, 2021. 
 
You asked the Plan to pay for the arthrodesis (22600). You say that procedure code 22600 is not bundled with 
22595. You say that the correct CPT codes were billed and 22600 should be processed for payment. The Plan 
denied your request. The Plan says procedure codes 22595, 63015, 22614 and 22843 were approved. The Plan 
also says procedure code 22600 is considered inclusive to CPT code 22595. 
 
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 22600 is arthrodesis, posterior or posterolateral 
technique, single level; cervical below C2 segment. 
 
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 the arthrodesis (22600). Our reviewer says that the 
documentation does not support the use of procedure code 22600. Our reviewer found the documentation does 
not state that there was a fusion for any cervical vertebra below C1-C2. 
  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the arthrodesis (22600) have not been met. Therefore, we decided that the Plan 
does not have to pay for the arthrodesis (22600) provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed. At this time, it is not 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block provided on February 18, 2022. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the genicular nerve block was 
medically necessary. The Plan denied your request. The Plan says the genicular nerve block was 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 a genicular nerve block. Our reviewer 
says that the genicular nerve block is not considered medically reasonable and necessary. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the genicular nerve blocks are considered 
experimental/investigational in nature. The requested genicular nerve block is not reasonable and 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block provided on February 18, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found there were no daily skilled nursing needs. 
Per Medicare the enrollee should be willing to participate in skilled therapy in order to be eligible for skilled 
therapy services. The record has consistent evidence the enrollee is not willing and able to participate in skilled 
therapy. Per chapter 8 Medicare benefit manual criteria not met. 
 
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.