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

 
We decided that the Plan does not have to pay for surgical services (69209) provided on October 13, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was not separately payable. 
 
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 69209 is not supported in the medical record. Specifically, this service has a 
professional component / technical component of 5 per the National Physician Fee Schedule and was billed 
with place of service 23. This service is not separately payable in this setting. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (69209) provided on October 13, 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 is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You have had a decline from your baseline level of function, 
but it is unlikely that you can participate in and benefit from the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
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 proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton therapy is reasonable and 
necessary in this case. The Plan denied your request. The Plan says while palliative radiation therapy is 
medically necessary, high-dose proton beam therapy is not. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton therapy for palliation of bladder cancer using a dose-fraction schedule 
commonly used for post-operative bladder sparing is not standard of care and is not supported by the evidence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes J2274 and J0735 for date of service January 13, 2022. 
 
You asked the Plan to pay for codes J2274 and J0735. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J2274 is injection, morphine sulfate, preservative-free for 
epidural or intrathecal use, 10 mg. 
The CPT Code Manual definition of code J0735 is injection, clonidine hydrochloride, 1 mg. 
 
We find that CPT codes J2274 and J0735 are not supported in the medical record. Specifically, the medical 
records indicate that the billed substances were included in a compounded drug. This means there are more 
appropriate codes to be billed for the services rendered. Based on this information, we decided that Medicare 
rules for coverage of codes J2274 and J0735 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes J2274 and J0735 for date of service January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array & Insertion of spinal neurostimulator (63650, 63685). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are requesting review for medical 
necessity for the procedure and equipment listed above. The facility will bill for the equipment to be used for 
this procedure. Please review for the doctor and facility. The Plan denied your request. The Plan says Under 
Medicare guidelines, your request is not medically necessary because your records do not show a positive 
response to your spinal cord stimulator trial. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that the enrollee has a diagnosis of chronic 
pain syndrome and lumbar radiculopathy. The record sent indicates that the enrollee is currently taking chronic 
pain medication. The enrollee had a spinal cord stimulator trial around March or April 2021. The response to this trial is not documented by the pain physician. Notes from an office visit note on July 15, 2021, with the 
Liver specialist state "Since the last visit the enrollee had a neurostimulator implant placed in their back with 
no benefit in their lower extremity pain and was removed."  
 
Only patients who experience a positive response to a trial should proceed to a permanent implantation. All 
trials which proceed to permanent implant must have adequate documentation in the chart to support that 
decision. A successful trial should be associated with at least a 50% reduction of target pain, or 50% reduction 
of analgesic medications, and show some element of functional improvement. (Patients with reflex sympathetic 
dystrophy may show lower levels of improvement since it takes longer periods for improvement than the 
typical one-to-two-week trial). The review has determined that the requested items/services at issue in this case 
are 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the percutaneous implantation of neurostimulator electrode array & Insertion of 
spinal neurostimulator (63650, 63685).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique (87481) 
 
You asked the Plan to pay for five units of 87481. You say that this panel was medically necessary. The Plan 
denied your request. The Plan says records do not contain lab results to support the 5 separate units of Candida 
species detection were performed 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the actual number of units 
provided on the claim form 
 
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 five units of 87481. Our reviewer says that this service is not 
supported. Our reviewer found that the units reported on the claim are not supported. The documentation does not support that five separate candida species were tested for. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five units of 87481 have not been met. Therefore, we decided that the Plan does 
not have to pay for five units of infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique (87481)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on February 
22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. 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 providers must report services correctly.  
 
We looked at the file and the rules. The MUE for code A0425 is 250. We find that CPT code A0425 was billed 
with 362 units. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
services provided on February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (27279). 
 
 
You asked the Plan to pre-approve the Pain TEQ LinQ device. You say that the LinQ implant is a safe and 
effective alternative to the lateral, titanium option. The Plan denied your request. The Plan says the clinical 
documentation provided and reviewed does not show the medical necessity. 
 
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 Pain TEQ LinQ device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation states that the enrollee has sacroiliac (SI) joint pain that 
affects their functional abilities. The physician has requested arthrodesis as above, but the intended procedure is 
placement of a LinQ implant which is an SI joint distraction device which allows placement of demineralized 
bone matrix (DBM) with the intention to stimulate bone growth across the joint. This procedure does not 
transfix the SI joint as is normally done with the traditional arthrodesis. The LinQ SI Joint Stabilization System 
provides patients with a minimally invasive option to combat pain due to sacroiliac disease. After a thorough 
diagnostic process, physicians may help alleviate, and in many cases eliminate, chronic pain by placing a single 
LinQ allograft into the SI joint. 
 
Currently, Medicare's coverage of the Pain TEQ LinQ device is still being studied to see if the treatment is 
reasonable and necessary. The enrollee is not enrolled in a Medicare approved study which is looking at the 
benefits of this management, nor does the current literature and guidance support this device. Overall, there is 
lack of evidence to support the Pain TEQ LinQ device over traditional treatment of SI joint pain with other 
methods of percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ). The review has 
determined that the items/services at issue in this case are 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 Pain TEQ LinQ device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of the heart. You say that you are allergic to your cholesterol 
medication, so you are unable to take it. You also say this this CT scan without dye for calcium scoring will 
help your provider make sure your cholesterol is staying under control. The Plan denied your request. The Plan 
says this test is not necessary when it is being used to screen enrollees with no symptoms. 
 
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 CT of the heart. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence showing that the use of coronary artery calcium (CAC) scores in clinical 
management of asymptomatic individuals leads to changes in patient management or in individual risk 
behaviors that improve cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart in 
guiding optimal management. Our physician reviewer also found that as such, CT imaging of the heart is 
considered experimental/investigational for the evaluation and management of your medical condition. 
 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 CT of the heart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the heart, without contrast material, with quantitative 
evaluation of coronary calcium (75571).
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 is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee has had a decline from her 
baseline level of function, but it is unlikely that she can participate in and benefit from the intensity of therapies 
provided on acute inpatient rehabilitation. 
 
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 repeat lumbar epidural steroid injection at the L4-L5 
level. 
 
You asked the Plan to pre-approve a repeat lumbar epidural steroid injection at the L4-L5 level. You say that a 
repeat lumbar epidural steroid injection at the L4-L5 level is medically necessary. The Plan denied your 
request. The Plan says a repeat lumbar epidural steroid injection at the L4-L5 level is not medically necessary. 
 
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 a repeat lumbar epidural steroid 
injection at the L4-L5 level. Our reviewer says that a repeat lumbar epidural steroid injection at the L4-L5 level 
is not medically necessary in this case. Our physician reviewer found that the enrollee tried physical therapy 
but was unable to tolerate it. The enrollee had an epidural steroid injection on September 15, 2022. The 
enrollee had 50 percent pain relief. On November 8, 2022, another ESI was requested. The Medicare LCD 
criteria is 3 months of 50 percent pain relief. This was not achieved and therefore, the request is deemed not 
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 a repeat lumbar epidural steroid injection at the L4-L5 level have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection at 
the L4-L5 level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on August 26, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this service is not separately payable. 
 
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 99214 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as code 28122 (partial excision (craterization, saucerization, sequestrectomy, or 
diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus). This 
means code 99214 is included in code 28122 as it was billed on the same date of service without an appropriate 
modifier. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on 
August 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that you have had functional and clinical status 
change. The documentation does not support the need for daily skilled services on an inpatient basis in a SNF. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Power Seat Lift Chair (PSLC). 
 
You asked the Plan to pre-approve a Power Seat Lift Chair (PSLC). You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a Power Seat Lift Chair (PSLC). Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the occupational therapy 
evaluation did not recommend a power lift chair. You are independent with transfers from a chair. You have 
difficulty transferring from low surfaces but decline to use an extra cushion for assistance. You can walk with a 
rollator and do not have severe arthritis of the hip or knee or severe neuromuscular disease. You are able to 
independently stand up from a regular armchair or any chair in the home.  
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 Power Seat Lift Chair (PSLC) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Power Seat Lift Chair (PSLC).